Medicare
Bulletin
Jurisdiction 15
Reaching Out
to the Medicare
Community
© 2015 Copyright, CGS Administrators, LLC.
HOME HEALTH & HOSPICE
FEBRUARY 2015 • WWW.CGSMEDICARE.COM
Jurisdiction 15
HOME HEALTH PROVIDERS
“Certifying Patients for the Medicare Home
Health Benefit” MLN Matters® Article — Released 3
MM8950 (Revised): Correction to Remittance
Information When Health Insurance Prospective
Payment System (HIPPS) Codes are Re-Coded
by Medicare Systems 4
MM8969 (Revised): Home Health Prospective
Payment System (HH PPS) Rate Update for
Calendar Year (CY) 2015 6
MM9014 (Revised): January 2015 Update
of the Hospital Outpatient Prospective
Payment System (OPPS) 11
MM9051: Modifications to Medicare Part B
Coverage of Pneumococcal Vaccinations 24
HOME HEALTH &
HOSPICE PROVIDERS
CGS Website Updates 27
Medicare Secondary Payer Explanation Codes 29
MM8901: Incorporation of Certain Provider
Enrollment Policies in CMS-4159-F into
Pub. 100-08, Program Integrity Manual (PIM),
Chapter 15 30
MM9005: January 2015 Integrated Outpatient
Code Editor (I/OCE) Specifications Version 16.0 31
HOME HEALTH & HOSPICE
Medicare Bulletin
MM9034: Summary of Policies in the Calendar
Year (CY) 2015 Medicare Physician Fee
Schedule (MPFS) Final Rule and Telehealth
Originating Site Facility Fee Payment Amount 34
MLN Connects™ Provider eNews 38
HOSPICE PROVIDERS
News Flash Messages from the Centers
for Medicare & Medicaid Services (CMS) 38
Reason Code 34952: Service Facility NPI
is Required 26
Provider Contact Center (PCC) Availability 39
Quarterly Provider Update 40
SE1435 (Revised): FAQs – International
Classification of Diseases, 10th Edition (ICD-10)
End-to-End Testing 40
SE1501: FAQs – International Classification
of Diseases, 10th Edition (ICD-10)
Acknowledgement Testing and End-to-End Testing 44
Seasonal Flu Vaccinations 46
Stay Informed and Join the CGS ListServ
Notification Service 47
Unsolicited/Voluntary Refunds 47
Upcoming Educational Events 48
http://go.cms.gov/MLNGenInfo
Update to the Interest Paid on Clean
Non-PIP Claims Not Paid Timely 48
Bold, italicized material is excerpted from the American Medical Association Current Procedural
Terminology CPT codes. Descriptions and other data only are copyrighted 2009 American Medical
Association. All rights reserved. Applicable FARS/DFARS apply.
MEDICARE BULLETIN • GR 2015-02
FEBRUARY 2015
2
The Medicare Learning Network® (MLN), offered by
the Centers for Medicare & Medicaid Services (CMS),
includes a variety of educational resources for health
care providers. Access Web-based training courses,
national provider conference calls, materials from
past conference calls, MLN articles, and much more.
To stay informed about all of the CMS MLN products,
refer to http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
Downloads/MailingLists_FactSheet.pdf and subscribe
to the CMS electronic mailing lists. Learn more about
what the CMS MLN offers at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html on the CMS website.
HOME HEALTH & HOSPICE
Medicare Learning Network®:
A Valuable Educational Resource!
For Home Health Providers
“Certifying Patients for the Medicare Home
Health Benefit” MLN Matters Article — Released
®
The following information was provided in the MLN Connects™ Provider eNews
for January 8, 2015, at: http://www.cms.gov/Outreach-and-Education/Outreach/
FFSProvPartProg/Downloads/2015-01-08-eNews.pdf
MLN Matters® Article #SE1436, “Certifying Patients for the Medicare Home Health
Benefit” at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1436.pdf was released and is now available
in downloadable format. This article is designed to provide education on the Medicare
home health services benefit, including patient eligibility requirements and certification/
recertification requirements of covered Medicare home health services. It includes
an overview of the Medicare home health services benefits and a list of eligibility and
certification requirements.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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FEBRUARY 2015
3
MM8950 (Revised): Correction to Remittance
Information When Health Insurance Prospective
Payment System (HIPPS) Codes are Re-Coded by
Medicare Systems
The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8950 Revised
Effective Date: April 1, 2015 (Effective for
Related CR Release Date: December 17, 2014 claims received on or after April 1, 2015)
Related CR Transmittal #: R3151CP
Implementation Date: April 6, 2015
Related Change Request (CR) #: CR 8950
Note: This article was revised on December 19, 2014, to reflect the revised CR 8950 issued on
December 17. In the article, all references to CARC 169 have been replaced with CARC 186. In
addition, the CR release date, transmittal number, and the Web address for accessing CR 8950 are
revised. All other information remains the same.
HOME HEALTH & HOSPICE
For Home Health Providers
Provider Types Affected
This MLN Matters® Article is intended for Inpatient Rehabilitation Facilities (IRFs), Home
Health Agencies (HHAs), and Skilled Nursing Facilities (SNFs) submitting claims to
Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs,
for services provided to Medicare beneficiaries.
Provider Action Needed
CR 8950 contains no new payment policy. CR 8950 improves the implementation
of existing policies.
CR 8950:
1. Provides approved remittance advice code pairs to apply to claims in which only
a Remittance Advice Remark Code (RARC) is currently used. This correction is
required for compliance with operating rules of the Phase III Council for Affordable
Quality Healthcare (CAQH) Committee on Operating Rules, for Information
Exchange (CORE).
2. Reflects changes to the Home Health (HH) Pricer logic that were implemented
as part of the 2015 Home Health Prospective Payment System (HH PPS)
payment update.
Make sure that your billing personnel are aware of these changes.
Background
The Phase III Council for Affordable Quality Healthcare (CAQH) Committee on Operating
Rules, for Information Exchange (CORE) Electronic Funds Transfer (EFT) & Electronic
Remittance Advice (ERA) Operating Rule Set was implemented by January 1, 2014,
as the Affordable Care Act required. In order to be compliant with these Operating
Rules, the processing of Original Medicare claims must use remittance advice code
combinations that are included in this list that CAQH CORE developed.
Recently, MACs informed CMS of two situations in which past instructions specified only
a single code for a payment adjustment, rather than a compliant pair.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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FEBRUARY 2015
4
2. In 2012, CR 7760 began the implementation of a process to validate HIPPS
codes against the assessment records submitted to the Quality Improvement
Evaluation System (QIES). This process currently applies to inpatient rehabilitation
facility claims and will be expanded to HH and skilled nursing facility claims in the
future. CR 7760 only required Medicare systems to apply RARC N69 to claims
recoded based on QIES data, also without a corresponding Claim Adjustment
Reason Code (CARC). You can find the associated MLN Matters® Article at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/mm7760.pdf on the CMS website.
CR 8950 seeks to correct these oversights. However, CAQH CORE has not yet assigned
approved code pairs for RARC N69. Medicare will request the approval of RARC N69
to be paired with CARC 186, Medicare systems will apply CARC 186 with RARC N69 in
both situations described above.
HOME HEALTH & HOSPICE
1. Since 2000, Medicare systems have re-coded the Health Insurance Prospective
Payment System (HIPPS) code submitted on home HH PPS claims in various
circumstances. Under prior instructions, Medicare systems applied only RARC
N69 (PPS code changed by claims processing system) without a corresponding
claim adjustment reason code (CARC).
Your MAC will:
1. Apply the following remittance advice codes on claims with Type of Bill (TOB) 032x
(Home Health Services under a Plan of Treatment) when the output HIPPS code
returned by the HH Pricer is different from the input HIPPS code:
ŠŠ Group code: CO
ŠŠ CARC: 186
ŠŠ RARC: N69
2. Apply the following remittance advice codes on claims with TOBs 011x (Hospital
Inpatient (Part A)) with CMS Certification Numbers (CCNs) XX3025 - XX3099,
XXTXXX, or XXRXXX, or TOBs 018x (Hospital Swing Bed), 021x (SNF Inpatient)
or 032x (Home Health) when a HIPPS code is changed due to response file
information received from QIES:
ŠŠ Group code: CO
ŠŠ CARC: 186
ŠŠ RARC: N69
HIPPS codes changed on the basis of validation with QIES data are not currently
displayed to providers on Direct Data Entry (DDE) screens and are not being sent to the
remittance advice.
CR 8950 also reflects changes to the HH Pricer logic that were implemented as part of
the 2015 HHPPS payment update. You can find these changes in the updated “Medicare
Claims Processing Manual,” Chapter 10 (Home Health Agency Billing), Section 70.4
(Decision Logic Used by the Pricer on Claims), which is attached to CR 8950.
Additional Information
The official instruction, CR 8950 issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R3151CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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FEBRUARY 2015
5
MM8969 (Revised): Home Health Prospective
Payment System (HH PPS) Rate Update for
Calendar Year (CY) 2015
The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8969 Revised
Related CR Release Date: December 9, 2014
Related CR Transmittal #: R3145CP
Related Change Request (CR) #: CR 8969
Effective Date: January 1, 2015
Implementation Date: January 5, 2015
Note: This article was revised on December 12, 2014, to reflect an updated Change Request (CR).
That CR corrected the wage index budget neutrality factors listed in the Policy Section of the Recurring
Update Notification. The wage index budget neutrality factors listed in the payment rate tables
were correct. The transmittal number, CR release date, and link to the CR also was changed. All other
information remains the same.
HOME HEALTH & HOSPICE
For Home Health Providers
Provider Types Affected
This MLN Matters® Article is intended for Home Health Agencies (HHAs) submitting
claims to Medicare Administrative Contractors (MACs) for services to Medicare
beneficiaries.
Provider Action Needed
CR 8969 informs MACs about the changes and updates to the 60-day national episode
rates, the national per-visit amounts, Low-Utilization Payment Adjustment (LUPA) add-on
amounts, and the non-routine medical supply payment amounts under the HH PPS for
Calendar Year (CY) 2015. Make sure that your billing staffs are aware of these changes.
Background
The Affordable Care Act of 2010 mandated several changes to Section 1895(b) of the
Social Security Act (or the Act) and hence the HH PPS Update for CY 2014.
Section 3131(a) of the Affordable Care Act mandates that, starting in CY 2014, the
Secretary must apply an adjustment to the national, standardized 60-day episode
payment rate and other amounts applicable under Section 1895(b)(3)(A)(i)(III) of the
Act to reflect factors such as changes in the number of visits in an episode, the mix of
services in an episode, the level of intensity of services in an episode, the average cost
of providing care per episode, and other relevant factors. In addition, Section 3131(a) of
the Affordable Care Act mandates that this rebasing must be phased in over a 4-year
period in equal increments, not to exceed 3.5 percent of the amount (or amounts), as of
the date of enactment, applicable under Section 1895(b)(3)(A)(i)(III) of the Act, and be
fully implemented by CY 2017.
Also, Section 3131(c) of the Affordable Care Act amended Section 421(a) of the Medicare
Modernization Act (MMA), which was amended by Section 5201(b) of the Deficit
Reduction Act (DRA). The amended Section 421(a) of the MMA provides an increase of 3
percent of the payment amount otherwise made under Section 1895 of the Act for home
health services furnished in a rural area (as defined in Section 1886(d)(2)(D) of the Act),
with respect to episodes and visits ending on or after April 1, 2010, and before January
1, 2016. The statute waives budget neutrality related to this provision, as the statute
specifically states that the Secretary shall not reduce the standard prospective payment
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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FEBRUARY 2015
6
Market Basket Update
The Multi-Factor Productivity (MFP) adjusted Home Health (HH) market basket update
for CY 2015 is 2.1 percent. HHAs that do not report the required quality data will receive
a 2-percentage point reduction to the MFP adjusted HH market basket update of 2.1
percent for CY 2015.
National, Standardized 60-Day Episode Payment
As described in the CY 2015 final rule, to determine the CY 2015 national, standardized
60-day episode payment rate, CMS starts with the CY 2014 national, standardized
60-day episode rate ($2,869.27). CMS applies a wage index budget neutrality factor of
1.0024 and a case-mix weight budget neutrality factor of 1.0366. CMS then applies an
$80.95 reduction (which is 3.5 percent of the CY 2010 national, standardized 60-day
episode rate of $2,312.94). Lastly, the national, standardized 60-day episode payment
rate is updated by the CY 2015 MFP adjusted HH market basket update of 2.1 percent
for HHAs that do submit the required quality data and by 0.1 percent for HHAs that do
not submit quality data. The updated CY 2015 national standardized 60-day episode
payment rate for HHAs that do submit the required quality data is shown in Table 1 below
and for HHAs that do not submit the required quality data are shown in Table 2 below.
These payments are further adjusted by the individual episode’s case-mix weight and
wage index.
HOME HEALTH & HOSPICE
amount (or amounts) under Section 1895 of the Act applicable to home health services
furnished during a period to offset the increase in payments resulting in the application of
this section of the statute.
Table 1: For HHAs that DO Submit Quality Data — National 60-Day Episode Amounts Updated by
the MFP adjusted Home Health Market Basket Update for CY 2015 Before Case-Mix Adjustment,
Wage Index Adjustment Based on the Site of Service for the Beneficiary
CY 2014 National,
Wage Index
Case-Mix
2015
CY 2015 HH
CY 2015 National,
Standardized 60-Day Budget
Weights Budget Rebasing
Payment Update Standardized 60-Day
Episode Payment
Neutrality Factor Neutrality Factor Adjustment Percentage
Episode Payment
$2,869.27
X 1.0024
X 1.0366
-$80.95
X 1.021
=$2,961.38
Table 2: For HHAs that DO NOT Submit Quality Data — National 60-Day Episode Amounts Updated
by the MFP adjusted Home Health Market Basket Update for CY 2015 Before Case-Mix Adjustment,
Wage Index Adjustment Based on the Site of Service for the Beneficiary
CY 2014 National, Wage Index
Standardized
Budget
Case-Mix
2015
CY 2015 HH Payment
CY 2015 National,
60-Day Episode
Neutrality
Weights Budget Rebasing
Update Percentage minus Standardized 60-Day
Payment
Factor
Neutrality Factor Adjustment 2 Percentage Points
Episode Payment
$2,869.27
X 1.0024
X 1.0366
-$80.95
X 1.001
=$2,903.37
National Per-Visit Rates
To calculate the CY 2015 national per-visit payment rates, CMS starts with the CY 2014
national per-visit rates. CMS applies a wage index budget neutrality factor of 1.0012 to
ensure budget neutrality for LUPA per-visit payments after applying the CY 2014 wage
index, and then applies the maximum rebasing adjustments to the 2014 per-visit rates.
The per-visit rates for each discipline are then updated by the MFP adjusted CY 2015
HH market basket update of 2.1 percent for HHAs that do submit the required quality
data and by 0.1 percent for HHAs that do not submit quality data. The CY 2015 national
per-visit rates per discipline for HHAs that do submit the required quality data are shown
in Table 3 below and for HHAs that do not submit the required quality data are shown in
Table 4 below.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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FEBRUARY 2015
7
CY 2015
Per-Visit
Payment
$57.89
$204.91
$140.70
$139.75
$127.83
$151.88
Table 4: For HHAs that DO NOT Submit Quality Data – CY 2015 National Per-Visit Amounts for
LUPAs and Outlier Calculations Updated by the MFP adjusted HH Market Basket Update, Before
Wage Index Adjustment
CY 2014
CY 2015
CY 2015 HH Payment
Per-Visit Wage Index Budget Rebasing
Update Percentage Minus
HH Discipline Type
Payment Neutrality Factor
Adjustment 2 Percentage Points
Home Health Aide
$54.84
X 1.0012
+$1.79
X 1.001
Medical Social Services
$194.12
X 1.0012
+$6.34
X 1.001
Occupational Therapy
$133.30
X 1.0012
+$4.35
X 1.001
Physical Therapy
$132.40
X 1.0012
+$4.32
X 1.001
Skilled Nursing
$121.10
X 1.0012
+$3.96
X 1.001
Speech- Language Pathology $143.88
X 1.0012
+$4.70
X 1.001
CY 2015
Per-Visit
Payment
$56.75
$200.89
$137.95
$137.02
$125.33
$148.90
HOME HEALTH & HOSPICE
Table 3: For HHAs that DO Submit Quality Data — CY 2015 National Per-Visit Amounts for LUPAs
and Outlier Calculations Updated by the MFP adjusted HH Market Basket Update, Before Wage
Index Adjustment
CY 2015
CY 2015 HH
CY 2014
Wage Index Budget Rebasing
Payment Update
HH Discipline Type
Per-Visit Payment Neutrality Factor
Adjustment Percentage
Home Health Aide
$54.84
X 1.0012
+$1.79
X 1.021
Medical Social Services
$194.12
X 1.0012
+$6.34
X 1.021
Occupational Therapy
$133.30
X 1.0012
+$4.35
X 1.021
Physical Therapy
$132.40
X 1.0012
+$4.32
X 1.021
Skilled Nursing
$121.10
X 1.0012
+$3.96
X 1.021
Speech- Language Pathology $143.88
X 1.0012
+$4.70
X 1.021
Low-Utilization Payment Adjustment Add-On Payments
Low-Utilization Payment Adjustment (LUPA) episodes that occur as initial episodes
in a sequence of adjacent episodes or as the only episode receive an additional
payment. Beginning in CY 2014, CMS calculates the payment for the first visit in a LUPA
episode by multiplying the per-visit rate by a LUPA add-on factor specific to the type
of visit (skilled nursing, physical therapy, or speech-language pathology). The specific
requirements for the new LUPA add-on calculation are described in Transmittal 2796
dated September 27, 2013. The CY 2015 LUPA add-on adjustment factors are displayed
in Table 5.
Table 5: CY 2015 LUPA Add-On factors
HH Discipline Type
Skilled Nursing
1.8451
Physical Therapy
1.6700
Speech-Language Pathology 1.6266
Non-Routine Supply Payments
Payments for Non-Routine Supplies (NRS) are computed by multiplying the relative
weight for a particular NRS severity level by the NRS conversion factor. To determine the
CY 2015 NRS conversion factor, CMS starts with the CY 2014 NRS conversion factor
($53.65) and applies a 2.82 percent rebasing adjustment calculated in the CY 2015 final
rule (1 - 0.0282 = 0.9718). CMS then updates the conversion factor by the MFP adjusted
HH market basket update of 2.1 percent for HHAs that do submit the required quality
data and by 0.1 percent for HHAs that do not submit quality data. CMS does not apply a
standardization factor as the NRS payment amount calculated from the conversion factor
is not wage or case-mix adjusted when the final claim payment amount is computed.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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Table 6a: CY 2015 NRS Conversion Factor for HHAs that DO Submit the Required Quality Data
CY 2015 HH Payment
CY 2015 NRS
CY 2014 NRS Conversion Factor 2015 Rebasing Adjustment Update Percentage
Conversion Factor
$53.65
X 0.9718
X 1.021
$53.23
Table 6b: CY 2015 Relative Weights and Payment Amounts for the 6-Severity NRS System
for HHAs that DO Submit Quality Data
Severity Level
Points (Scoring)
Relative Weight
CY 2015 NRS Payment Amount
1
0
0.2698
$14.36
2
1 to 14
0.9742
$51.86
3
15 to 27
2.6712
$142.19
4
28 to 48
3.9686
$211.25
5
49 to 98
6.1198
$325.76
6
99+
10.5254
$560.27
HOME HEALTH & HOSPICE
The NRS conversion factor for CY 2015 payments for HHAs that do submit the required
quality data is shown in Table 6a and the payment amounts for the various NRS severity
levels are shown in Table 6b. The NRS conversion factor for CY 2015 payments for
HHAs that do not submit quality data is shown in Table 7a and the payment amounts for
the various NRS severity levels are shown in Table 7b.
Table 7a: CY 2015 NRS Conversion Factor for HHAs that DO NOT Submit the Required Quality Data
CY 2014 NRS
CY 2015 HH Payment Update
CY 2015 NRS
Conversion Factor 2015 Rebasing Adjustment Percentage minus 2 Percentage Points
Conversion Factor
$53.65
X 0.9718
X 1.001
$52.19
Table 7b: CY 2015 Relative Weights and Payment Amounts for the 6-Severity NRS System for HHAs that DO NOT
Submit Quality Data
Severity Level
Points (Scoring)
Relative Weight
CY 2015 NRS Payment Amount
1
0
0.2698
$14.08
2
1 to 14
0.9742
$50.84
3
15 to 27
2.6712
$139.41
4
28 to 48
3.9686
$207.12
5
49 to 98
6.1198
$319.39
6
99+
10.5254
$549.32
Rural Add-on
Section 3131(c) of the Affordable Care Act applies a 3 percent rural add-on to the
national standardized 60-day episode rate, national per-visit payment rates, LUPA addon payments, and the NRS conversion factor when home health services are provided
in rural (non-CBSA) areas for episodes and visits ending on or after April 1, 2010, and
before January 1, 2016. The following tables show the CY 2015 rural payment rates.
Table 8a: CY 2015 Payment Amounts for 60-Day Episodes for Services Provided
in a Rural Area before Case-Mix and Wage Index Adjustment for HHAs that DO Submit Quality Data
CY 2015 National, Standardized
CY 2015 Rural National, Standardized
60-Day Episode Payment Rate
Multiply by the 3 Percent Rural Add-On 60-Day Episode Payment Rate
$2,961.38
X 1.03
$3,050.22
Table 8b: CY 2015 Payment Amounts for 60-Day Episodes for Services Provided in a Rural Area
before Case-Mix and Wage Index Adjustment for HHAs that DO NOT Submit Quality Data
CY 2015 National Standardized
CY 2015 Rural National, Standardized
60-Day Episode Payment Rate
Multiply by the 3 Percent Rural Add-On 60-Day Episode Payment Rate
$2,903.37
X 1.03
$2,990.47
This newsletter should be shared with all health care practitioners and managerial members
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Table 9b: CY 2015 Per-Visit Amounts for Services Provided in a Rural Area, Before Wage Index
Adjustment for HHAs that DO NOT submit quality data
Multiply by the 3 Percent Rural
Home Health Discipline Type CY 2015 Per-visit rate Add-On
CY 2015 Rural per-visit rate
HH Aide
$56.75
X 1.03
$58.45
MSS
$200.89
X 1.03
$206.92
OT
$137.95
X 1.03
$142.09
PT
$137.02
X 1.03
$141.13
SN
$125.33
X 1.03
$129.09
SLP
$148.90
X 1.03
$153.37
HOME HEALTH & HOSPICE
Table 9a: CY 2015 Per-Visit Amounts for Services Provided in a Rural Area, Before Wage Index
Adjustment for HHAs that DO Submit Quality Data
Multiply by the 3 Percent Rural
Home Health Discipline Type CY 2015 Per-visit rate Add-On
CY 2015 Rural per-visit rate
HH Aide
$57.89
X 1.03
$59.63
MSS
$204.91
X 1.03
$211.06
OT
$140.70
X 1.03
$144.92
PT
$139.75
X 1.03
$143.94
SN
$127.83
X 1.03
$131.66
SLP
$151.88
X 1.03
$156.44
Table 10a: CY 2015 Conversion Factor for Services Provided in Rural Areas for HHAs that DO
Submit Quality Data
CY 2015 Conversion Factor Multiply by the 3 Percent Rural Add-On
CY 2015 Rural Conversion Factor
$53.23
X 1.03
$54.83
Table 10b: CY 2015 Conversion Factor for Services Provided in Rural Areas for HHAs that DO NOT
Submit Quality Data
CY 2015 Conversion Factor Multiply by the 3 Percent Rural Add-On
CY 2015 Rural Conversion Factor
$52.19
X 1.03
$53.76
Table 10c: CY 2015 Relative Weights and Payment Amounts for the 6-Severity NRS System
for Services Provided in Rural Areas for HHAs that DO submit quality data
Severity Level Points (Scoring) Relative Weight Total CY 2015 NRS Payment Amount for Rural Areas
1
0
0.2698
$14.79
2
1 to 14
0.9742
$53.42
3
15 to 27
2.6712
$146.46
4
28 to 48
3.9686
$217.60
5
49 to 98
6.1198
$335.55
6
99+
10.5254
$577.11
Table 10d: CY 2015 Relative Weights and Payment Amounts for the 6-Severity NRS System
for Services Provided in Rural Areas for HHAs that DO NOT submit quality data
Severity Level Points (Scoring) Relative Weight Total CY 2015 NRS Payment Amount for Rural Areas
1
0
0.2698
$14.50
2
1 to 14
0.9742
$52.37
3
15 to 27
2.6712
$143.60
4
28 to 48
3.9686
$213.35
5
49 to 98
6.1198
$329.00
6
99+
10.5254
$565.85
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HHAs should remember to:
yySubmit the Core Based Statistical Area (CBSA) code or special wage index code
corresponding to the state and county of the beneficiary’s place of residence in value
code 61 on home health Requests for Anticipated Payments (RAPs) and claims;
yyUse the wage index table attached to CR 8969, which associates states and
counties to CBSA codes (codes in the range 10020 – 49780 and 999xx rural state
codes) to determine the code to report in value code 61;
yyUse the codes in the range 50xxx in the wage index table attached to CR 8969 to
determine the code to report in value code 61 if the provider serves beneficiaries in
areas where there is more than one unique CBSA due to the wage index transition.
Additional Information
The official instruction, CR 8969, issued to your MAC regarding this change, is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R3145CP.pdf on the CMS website.
HOME HEALTH & HOSPICE
These changes are to be implemented through the Home Health Pricer software found in
Medicare contractor standard systems.
For Home Health Providers
MM9014 (Revised): January 2015 Update
of the Hospital Outpatient Prospective
Payment System (OPPS)
The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning
Network® (MLN) Matters article on December 18, 2014. CMS then issued a revision to this article on
December 24, 2014. The following reflects the revised article. This MLN Matters article and other CMS
articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM9014 Revised
Related Change Request (CR) #: CR9014
Related CR Release Date: December 22, 2014 Effective Date: January 1, 2015
Related CR Transmittal #: R3156CP
Implementation Date: January 5, 2015
Note: This article was revised on December 23, 2014, based on a revised Change Request (CR) that
corrected some values in Table 8, which addressed changes to the Outpatient Provider Specific File.
That Table is in Attachment A of the CR, but was not included in this article. The CR Release Date,
transmittal number and link to the CR was also changed. All other information remains the same.”
Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers who submit claims
to Medicare Administrative Contractors (MACs) for services provided to Medicare
beneficiaries and paid under the Outpatient Prospective Payment System (OPPS).
Provider Action Needed
CR 9014 describes changes to and billing instructions for various payment policies
implemented in the January 2015 OPPS update. Make sure your billing staffs are aware
of these changes.
Background
CR 9014 describes changes to and billing instructions for various payment policies
implemented in the January 2015 Outpatient Prospective Payment System (OPPS)
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The January 2015 revisions to I/OCE data files, instructions, and specifications are
provided in CR 9005. The MLN Matters® Article related to CR 9005 is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/MM9005.pdf on the CMS website.
Key changes to and billing instructions for various payment policies implemented in the
January 2015, OPPS update are as follows:
New Service
The new service listed in Table 1 is assigned for payment under the OPPS, effective
January 1, 2015.
Table 1 – New Service Assigned for Payment under OPPS, Effective January 1, 2015
Effective
Short
HCPCS Date
SI APC Descriptor
Long Descriptor
Payment
C9742 01/01/2015 T 0073 Laryngoscopy Laryngoscopy, flexible fiberoptic, $1259.06
with injection
with injection into vocal cord(s),
therapeutic, including diagnostic
laryngoscopy, if performed
Minimum Unadjusted
Copayment
$251.82
HOME HEALTH & HOSPICE
update. The January 2015 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer
will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory
Payment Classification (APC), HCPCS Modifier, Status Indicators (SIs)and Revenue
Code additions, changes, and deletions identified in CR 9014.
New Device Pass-Through Categories
The Social Security Act (Section 1833(t)(6)(B); see http://www.ssa.gov/OP_Home/ssact/
title18/1833.htm) requires that, under the OPPS, categories of devices be eligible for
transitional pass-through payments for at least 2, but not more than 3 years. Section
1833(t)(6)(B)(ii)(IV) of the Social Security Act (the Act) requires that CMS create
additional categories for transitional pass-through payment of new medical devices not
described by existing or previously existing categories of devices.
CMS is establishing one new device pass-through category as of January 1, 2015. Table
2 provides a listing of new coding and payment information concerning the new device
category for transitional pass-through payment.
Table 2 – New Device Pass-Through Code
HCPCS Effective Date SI
C2624 01/01/15
H
APC Short Descriptor
2624 Wireless pressure sensor
Device Offset
Long Descriptor
from Payment
Implantable wireless pulmonary artery $310.33
pressure sensor with delivery catheter,
including all system components
a. Device Offset from Payment: Section 1833(t)(6)(D)(ii) of the Act requires that CMS
deduct from pass-through payments for devices an amount that reflects the portion of the
APC payment amount that CMS determines is associated with the cost of the device (70
FR 68627-8).
CMS has determined that a portion of the APC payment amount associated with the
cost of C2624 is reflected in APC 0080, Diagnostic Cardiac Catheterization. The C2624
device should always be billed with procedure code C9741 (Right heart catheterization
with implantation of wireless pressure sensor in the pulmonary artery, including any type
of measurement, angiography, imaging supervision, interpretation, and report), which
is assigned to APC 0080 for CY 2015. The device offset from payment represents a
deduction from pass-through payments for the device in category C2624. Therefore,
CMS is establishing the offset amount for C2624 to be that of APC 0080, $310.33, which
will be deducted from pass-through payment.
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For CY 2015, CMS is creating a new category of codes, called “Comprehensive APCs,”
for which CMS provides a single claim payment. Through OCE logic, the PRICER will
automatically assign payment for a “Comprehensive APC” service reported on a claim.
Both the OCE and the PRICER will implement these new policies without any coding
change required on the part of hospitals.
Effective January 1, 2015, comprehensive APCs (Identified by a new Status Indicator, J1)
provide a single payment for a primary service, and payment for all adjunctive services
reported on the same claim is packaged into payment for the primary service.
CMS is updating the “Medicare Claims Processing Manual,” (Chapter 4, by adding
Section 10.2.3 and revising Section 10.4 to reflect comprehensive APC payment policies.
The added Section 10.2.3 (Comprehensive APCs) and revised Section 10.4 (Packaging)
are included in CR 9014. The added Section 10.2.3 states the following:
HCPCS codes assigned to comprehensive APCs are designated with status indicator
J1, See Addendum B at http://www.cms.hhs.gov/HospitalOutpatientPPS/ for the list of
HCPCS codes designated with status indicator J1.
Claims reporting at least one J1 procedure code will package the following items and
services that are not typically packaged under the OPPS:
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Comprehensive APCs
yyMajor OPPS procedure codes (status indicators P, S, T, V);
yyLower ranked comprehensive procedure codes (status indicator J1);
yyNon-pass-through drugs and biologicals (status indicator K);
yyBlood products (status indicator R);
yyDME (status indicator Y); and
yyTherapy services (HCPCS codes with status indicator A reported on therapy revenue
centers).
The following services are excluded from comprehensive APC packaging:
yyBrachytherapy sources (status indicator U);
yyPass-through drugs, biologicals and devices (status indicators G or H);
yyCorneal tissue, CRNA services, and Hepatitis B vaccinations (status indicator F);
yyInfluenza and pneumococcal pneumonia vaccine services (status indicator L);
yyAmbulance services;
yyMammography; and
yyCertain preventive services
The single payment for a comprehensive claim is based on the rate associated with
the J1 service. When multiple J1 services are reported on the same claim, the single
payment is based on the rate associated with the highest ranking J1 service. When
certain pairs of J1 services (or in certain cases a J1 service and an add-on code)
are reported on the same claim, the claim is eligible for a complexity adjustment,
which provides a single payment for the claim based on the rate of the next higher
comprehensive APC within the same clinical family. Note that complexity adjustments will
not be applied to discontinued services (reported with modifier -73 or -74).
Billing for Corneal Tissue
CMS reminds hospitals that according to the “Medicare Claims Processing
Manual” (Chapter 4, Section 200.1 at http://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Downloads/clm104c04.pdf), the corneal tissue is paid on a cost
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Billing for Mobile Cardiac Telemetry Monitoring Services
Current Procedural Terminology (CPT) code 93229 describes wearable mobile
cardiovascular telemetry services. As instructed in the CY 2015 OPPS/ASC final
rule, CPT code 93229 should be used to report continuous outpatient cardiovascular
monitoring that includes up to 30 consecutive days of real-time cardiac monitoring. In
particular, the 2015 CPT Code Book defines CPT code 93229 as:
Mobile Cardiovascular Telemetry (MCT): continuously records the
electrocardiographic rhythm from external electrodes placed on the
patient’s body. Segments of the ECG data are automatically (without
patient intervention) transmitted to a remote surveillance location by
cellular or landline telephone signal. The segments of the rhythm, selected
for transmission, are triggered automatically (MCT device algorithm) by
rapid and slow heart rates or by the patient during a symptomatic episode.
There is continuous real time data analysis by preprogrammed algorithms
in the device and attended surveillance of the transmitted rhythm
segments by a surveillance center technician to evaluate any arrhythmias
and to determine signal quality. The surveillance center technician
reviews the data and notifies the physician or other qualified health care
professional depending on the prescribed criteria (2015 CPT Professional
Edition; page 578).
HOME HEALTH & HOSPICE
basis and not under the OPPS. To receive cost based reimbursement for corneal tissue,
hospitals must bill charges for corneal tissue using HCPCS code V2785.
CMS expects that hospitals will report CPT code 93229 on hospital claims only when
they have provided the mobile telemetry service as described above.
For information on the APC assignment, OPPS status indicator, and payment rate for
CPT code 93229 effective January 1, 2015, refer to Addendum B of the January 2015
OPPS Update that is posted at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html on the
CMS website.
Billing for “Sometimes Therapy” Services that May be
Paid as Non-Therapy Services for Hospital Outpatients
The Social Security Act (Section 1834(k); see http://www.ssa.gov/OP_Home/ssact/
title18/1834.htm, as added by Section 4541 of the Balanced Budget Act (BBA), allows
payment at 80 percent of the lesser of the actual charge for the services or the applicable
fee schedule amount for all outpatient therapy services; that is, physical therapy
services, speech-language pathology services, and occupational therapy services. As
provided under Section 1834(k)(5) of the Act, a therapy code list was created based on a
uniform coding system (that is, the HCPCS) to identify and track these outpatient therapy
services paid under the Medicare Physician Fee Schedule (MPFS).
The list of therapy codes, along with their respective designation, can be found at
http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage
on the CMS website. Two of the designations that are used for therapy services
are: “always therapy” and “sometimes therapy.” An “always therapy” service must
be performed by a qualified therapist under a certified therapy plan of care, and a
“sometimes therapy” service may be performed by physician or a non-physician
practitioner outside of a certified therapy plan of care.
Under the OPPS, separate payment is provided for certain services designated as
“sometimes therapy” services if these services are furnished to hospital outpatients
as a non-therapy service, that is, without a certified therapy plan of care. Specifically,
to be paid under the OPPS for a non-therapy service, hospitals SHOULD NOT
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To receive payment under the MPFS, when “sometimes therapy” services are performed
by a qualified therapist under a certified therapy plan of care, providers should append
the appropriate therapy modifier GP, GO, or GN, and report the charges under an
appropriate therapy revenue code, specifically 042x, 043x, or 044x. This instruction does
not apply to claims for “sometimes therapy” codes furnished as non-therapy services in
the hospital outpatient department and paid under the OPPS.
Effective January 1, 2015, two HCPCS codes designated as “Sometimes Therapy”
services, G0456 (Negative pressure wound therapy, (e.g. vacuum assisted drainage
collection) using a mechanically-powered device, not durable medical equipment,
including provision of cartridge and dressing(s), topical application(s), wound
assessment, and instructions for ongoing care, per session; total wounds(s) surface
area less than or equal to 50 square centimeters) and G0457 (Negative pressure
wound therapy, (e.g. vacuum assisted drainage collection) using a mechanicallypowered device, not durable medical equipment, including provision of cartridge and
dressing(s), topical application(s), wound assessment, and instructions for ongoing
care, per session; total wounds(s) surface area greater than 50 square centimeters)
would be terminated and replaced with two new CPT codes 97607 (Negative pressure
wound therapy, (for example, vacuum assisted drainage collection), utilizing disposable,
non-durable medical equipment including provision of exudate management collection
system, topical application(s), wound assessment, and instructions for ongoing care,
per session; total wounds(s) surface area less than or equal to 50 square centimeters)
and 97608 (Negative pressure wound therapy, (for example, vacuum assisted drainage
collection), utilizing disposable, non-durable medical equipment including provision of
exudate management collection system, topical application(s), wound assessment, and
instructions for ongoing care, per session; total wounds(s) surface area greater than 50
square centimeters).
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append the therapy modifier GP (physical therapy), GO (occupational therapy), or GN
(speech language pathology), or report a therapy revenue code 042x, 043x, or 044x in
association with the “sometimes therapy” codes listed in Table 3 below.
The list of HCPCS codes designated as “sometimes therapy” services that may be paid
as non-therapy services when furnished to hospital outpatients is displayed in Table 3.
Table 3 – Services Designated as “Sometimes Therapy” that May be Paid as Non-Therapy Services
for Hospital Outpatients
HCPCS Code Long Descriptor
92520
Laryngeal function studies (i.e., aerodynamic testing and acoustic testing)
97597
Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (for example, high
pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps),
with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include
use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters
97598
Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (for example,, high
pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps),
with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include
use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters
97602
Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (for example,,
wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and
instruction(s) for ongoing care, per session
97605
Negative pressure wound therapy (for example,, vacuum assisted drainage collection), including topical
application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface
area less than or equal to 50 square centimeters
97606
Negative pressure wound therapy (for example,, vacuum assisted drainage collection), including topical
application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface
area greater than 50 square centimeters
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97607
Negative pressure wound therapy, (for example, vacuum assisted drainage collection), utilizing disposable,
non-durable medical equipment including provision of exudate management collection system, topical
application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface
area less than or equal to 50 square centimeters
97608
Negative pressure wound therapy, (for example, vacuum assisted drainage collection), utilizing disposable,
non-durable medical equipment including provision of exudate management collection system, topical
application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface
area greater than 50 square centimeters
97610
Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed,
wound assessment, and instruction(s) for ongoing care, per day
New Laboratory HCPCS G-codes Effective January 1, 2015
For the CY 2015 update, the CPT Editorial Panel deleted several laboratory services on
December 31, 2014, and replaced them with new CPT codes effective January 1, 2015.
Because the laboratory services described by the 2014 CPT codes (which are being
deleted) will continue to be paid under the Clinical Lab Fee Schedule (CLFS) in 2015,
Medicare has established the following HCPCS G-codes to replace the deleted CPT
codes for these laboratory services. Under the hospital OPPS, the HCPCS G-codes are
assigned to status indicator “N” (packaged) effective January 1, 2015. In addition, the
new laboratory CY 2015 CPT codes that replaced the deleted laboratory CY 2014 CPT
codes have been assigned to status indicator “B” to indicate that another code should
be reported under the hospital OPPS. The list of the new HCPCS G-codes and their
predecessor CPT codes are in Table 4.
Table 4—New HCPCS G-codes and their Predecessor CPT codes
CY 2014
CY 2014 CPT Long Descriptor
CY 2015
CY 2015 HCPCS G-code Long
CPT Code
HCPCS Code Descriptor
CY 2015
OPPS SI
80102
Drug confirmation, each procedure
G6058
Drug confirmation, each procedure
N
80152
Amitriptyline
G6030
Amitriptyline
N
80154
Benzodiazepines
G6031
Benzodiazepines
N
80160
Desipramine
G6032
Desipramine
N
80166
Doxepin
G6034
Doxepin
N
80172
Gold
G6035
Gold
N
80174
Imipramine
G6036
Imipramine
N
80182
Nortriptyline
G6037
Nortriptyline
N
80196
Salicylate
G6038
Salicylate
N
82003
Acetaminophen
G6039
Acetaminophen
N
82055
Alcohol (ethanol); any specimen except
breath
G6040
Alcohol (ethanol); any specimen
except breath
N
82101
Alkaloids, urine, quantitative
Amphetamine or methamphetamine
Barbiturates, not elsewhere specified
G6041
82145
82205
G6042
G6043
N
N
N
82520
82646
82649
82651
82654
Cocaine or metabolite
Dihydrocodeinone
Dihydromorphinone
Dihydrotestosterone (DHT)
Dimethadione
G6044
G6045
G6046
G6047
G6048
Alkaloids, urine, quantitative
Amphetamine or methamphetamine
Barbiturates, not elsewhere
specified
Cocaine or metabolite
Dihydrocodeinone
Dihydromorphinone
Dihydrotestosterone (DHT)
Dimethadione
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Table 3 – Services Designated as “Sometimes Therapy” that May be Paid as Non-Therapy Services
for Hospital Outpatients
HCPCS Code Long Descriptor
N
N
N
N
N
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FEBRUARY 2015
16
CY 2015 HCPCS G-code Long
Descriptor
Epiandrosterone
Ethchlorvynol
Flurazepam
Meprobamate
Methadone
Methsuximide
Nicotine
Opiate(s), drug and metabolites,
each procedure
Phenothiazine
CY 2015
OPPS SI
N
N
N
N
N
N
N
N
N
Coding Guidance for Intraocular or Periocular Injections
of Combinations of Anti-Inflammatory Drugs and Antibiotics
Intraocular or periocular injections of combinations of anti-inflammatory drugs and
antibiotics are being used with increased frequency in ocular surgery (primarily cataract
surgery). One example of combined or compounded drugs includes triamcinolone and
moxifloxacin with or without vancomycin. Such combinations may be administered as
separate injections or as a single combined injection. Because such injections may
obviate the need for post-operative anti-inflammatory and antibiotic eye drops, some
have referred to cataract surgery with such injections as “dropless cataract surgery.”
HOME HEALTH & HOSPICE
Table 4—New HCPCS G-codes and their Predecessor CPT codes
CY 2014
CY 2014 CPT Long Descriptor
CY 2015
CPT Code
HCPCS Code
82666
G6049
Epiandrosterone
82690
G6050
Ethchlorvynol
82742
G6051
Flurazepam
83805
G6052
Meprobamate
83840
G6053
Methadone
83858
G6054
Methsuximide
83887
G6055
Nicotine
83925
G6056
Opiate(s), drug and metabolites, each
procedure
84022
G6057
Phenothiazine
As stated in Chapter VIII, Section D, Item 20 of the CY 2015 “National Correct Coding
Initiative (NCCI) Policy Manual,” injection of a drug during a cataract extraction procedure
or other ophthalmic procedure is not separately reportable. Specifically, no separate
procedure code may be reported for any type of injection during surgery or in the
perioperative period. Injections are a part of the ocular surgery and are included as a
part of the ocular surgery and the HCPCS code used to report the surgical procedure.
According to the“ Medicare Claims Processing Manual” (Chapter 17, Section 90.2;
see http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/
clm104c17.pdf), the compounded drug combinations described above and similar
drug combinations should be reported with HCPCS code J3490 (Unclassified
drugs), regardless of the site of service of the surgery, and are packaged as surgical
supplies in both the HOPD and the ASC. Although these drugs are a covered part of
the ocular surgery, no separate payment will be made. In addition, these drugs and
drug combinations may not be reported with HCPCS code C9399. According to the
“Medicare Claims Processing Manual” (Chapter 30, Section 40.3.6; http://www.cms.gov/
Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf on the CMS
website) physicians or facilities should not give Advance Beneficiary Notices (ABNs)
to beneficiaries for either these drugs or for injection of these drugs because they are
fully covered by Medicare. Physicians or facilities are not permitted to charge the patient
an extra amount (beyond the standard copayment for the surgical procedure) for these
injections or the drugs used in these injections because they are a covered part of the
surgical procedure. Also, physicians or facilities cannot circumvent packaged payment
in the HOPD or ASC for these drugs by instructing beneficiaries to purchase and bring
these drugs to the facility for administration.
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a. New CY 2015 HCPCS Codes and Dosage Descriptors for Certain Drugs,
Biologicals, and Radiopharmaceuticals
For CY 2015, several new HCPCS codes have been created for reporting drugs and
biologicals in the hospital outpatient setting, where there have not previously been
specific codes available. These new codes are listed in Table 5.
Table 5 – New CY 2015 HCPCS Codes Effective for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2015
CY
HCPCS Code CY 2015 Long Descriptor
2015 SI CY 2015 APC
A9606
Radium ra-223 dichloride, therapeutic, per microcurie
K
1745
C9027
Injection, pembrolizumab, 1 mg
G
1490
C9136
Injection, factor viii, fc fusion protein, (recombinant), per i.u.
G
1656
C9349
FortaDerm, and FortaDerm Antimicrobial, any type, per square centimeter
G
1657
C9442
Injection, belinostat, 10 mg
G
1658
C9443
Injection, dalbavancin, 10 mg
G
1659
C9444
Injection, oritavancin, 10 mg
G
1660
C9446
Injection, tedizolid phosphate, 1 mg
G
1662
C9447
Injection, phenylephrine and ketorolac, 4 ml vial
G
1663
J0571
Buprenorphine, oral, 1 mg
E
J0572
Buprenorphine/naloxone, oral, less than or equal to 3 mg
E
J0573
Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg
E
J0574
Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg
E
J0575
Buprenorphine/naloxone, oral, greater than 10 mg
E
J1826
Injection, interferon beta-1a, 30 mcg
E
J2704
Injection, Propofol, 10mg
N
J7182
Factor viii, (antihemophilic factor, recombinant), (novoeight), per iu
E
J7301
Levonorgestrel-releasing intrauterine contraceptive system, 13.5mg
E
J7302
Levonorgestrel-releasing intrauterine contraceptive system, 52 mg
E
J7327
Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose
K
J8565
Gefitinib, oral, 250 mg
E
Q4150
Allowrap dds or dry, per square centimeter
N
Q4151
Amnioband or guardian, per square centimeter
N
Q4152
Dermapure, per square centimeter
N
Q4153
Dermavest, per square centimeter
N
Q4154
Biovance, per square centimeter
N
Q4155
Neoxflo or Clarixflo, 1 mg
N
Q4156
Neox 100, per square centimeter
N
Q4157
Revitalon, per square centimeter
N
Q4158
Marigen, per square centimeter
N
Q4159
Affinity, per square centimeter
N
Q4160
Nushield, per square centimeter
N
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Drugs, Biologicals, and Radiopharmaceuticals
1747
b. Other Changes to CY 2015 HCPCS and CPT Codes for Certain Drugs,
Biologicals, and Radiopharmaceuticals
Many HCPCS and CPT codes for drugs, biologicals, and radiopharmaceuticals have
changes in their HCPCS and CPT code descriptors that will be effective in CY 2015. In
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Table 6 below notes those drugs, biologicals, and radiopharmaceuticals that have
changes in their HCPCS/CPT code, their long descriptor, or both. Each product’s
CY 2014 HCPCS/CPT code and long descriptor are noted in the two left hand columns
and the CY 2015 HCPCS/CPT code and long descriptor are noted in the adjacent
right hand columns.
Table 6 – Other CY 2015 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2014 HCPCS/ CY 2014 Long Descriptor
CY 2015 HCPCS/ CY 2015 Long Descriptor
CPT code
CPT Code
J7195
Factor ix (antihemophilic factor,
recombinant) per i.u.
J7195
Injection, Factor ix (antihemophilic
factor, recombinant) per iu, not
otherwise specified
J7301
Levonorgestrel-releasing intrauterine
contraceptive system (Skyla), 13.5mgJ
J7301
Levonorgestrel-releasing intrauterine
contraceptive system, 13.5mg
Q4119
Matristem wound matrix, psmx, rs, or
psm, per square centimeter
Q4119
Matristem wound matrix, per square
centimeter
Q4147
Architect, extracellular matrix, per square
centimeter
Q4147
Architect, architect px, or architect
fx, extracellular matrix, per square
centimeter
C9021
Injection, obinutuzumab, 10 mg
J9301
Injection, obinutuzumab, 10 mg
C9022
Injection, elosulfase alfa, 1mg
J1322
Injection, elosulfase alfa, 1mg
C9023
Injection, testosterone undecanoate, 1 mg J3145
C9133
Factor ix (antihemophilic factor,
recombinant), Rixubis, per i.u.
J7200
Factor ix (antihemophilic factor,
recombinant), Rixubis, per i.u.
C9134
Factor XIII (antihemophilic factor,
recombinant), Tretten, per i.u.
J7181
Factor XIII (antihemophilic factor,
recombinant), Tretten, per i.u.
C9135
Factor ix (antihemophilic factor,
recombinant), Alprolix, per i.u.
J7201
Factor ix (antihemophilic factor,
recombinant), Alprolix, per i.u.
J0150
Injection, adenosine for therapeutic
use, 6 mg (not to be used to report
any adenosine phosphate compounds,
instead use a9270)
J0153
Injection, adenosine for therapeutic
use, 6 mg (not to be used to report
any adenosine phosphate compounds,
instead use a9270)
J0151
Injection, adenosine for diagnostic
use, 1 mg (not to be used to report
any adenosine phosphate compounds,
instead use a9270)
J0153
Injection, adenosine for diagnostic
use, 1 mg (not to be used to report
any adenosine phosphate compounds,
instead use a9270)
J1070
Injection, testosterone cypionate, up to
100 mg
J1071
Injection, testosterone cypionate, 1mg
J1080
Injection, testosterone cypionate, 1 cc,
200 mg
J1071
Injection, testosterone cypionate, 1mg
J2271
Injection, morphine sulfate, 100mg
J2274
Injection, morphine sulfate,
preservative-free for epidural or
intrathecal use, 10mg
J2275
Injection, morphine sulfate (preservativefree sterile solution), per 10 mg
J2274
Injection, morphine sulfate,
preservative-free for epidural or
intrathecal use, 10mg
J3120
Injection, testosterone enanthate, up to
100 mg
J3121
Injection, testosterone enanthate, 1mg
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addition, several temporary HCPCS C-codes have been deleted effective December
31, 2014, and replaced with permanent HCPCS codes in CY 2015. Hospitals should
pay close attention to accurate billing for units of service consistent with the dosages
contained in the long descriptors of the active CY 2015 HCPCS and CPT codes.
Injection, testosterone undecanoate,
1 mg
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FEBRUARY 2015
19
J3130
Injection, testosterone enanthate, up to
200 mg
J3121
Injection, testosterone enanthate, 1mg
J7335
Capsaicin 8% patch, per 10 square
centimeters
J7336
Capsaicin 8% patch, per square
centimeter
J9265
Injection, paclitaxel, 30 mg
J9267
Injection, paclitaxel, 1 mg
Q9970
Injection, ferric carboxymaltose, 1mg
J1439
Injection, ferric carboxymaltose, 1 mg
Q9972
Injection, epoetin beta, 1 microgram, (For
ESRD On Dialysis)
J0887
Injection, epoetin beta, 1 microgram,
(for esrd on dialysis)
Q9973
Injection, Epoetin Beta, 1 microgram,
(Non-ESRD use)
J0888
Injection, epoetin beta, 1 microgram,
(for non esrd use)
Q9974
Injection, morphine sulfate (preservativefree sterile solution), per 10 mg
J2274
Injection, morphine sulfate,
preservative-free for epidural or
intrathecal use, 10mg
S0144
Injection, Propofol, 10mg
J2704
Injection, Propofol, 10mg
c. Drugs and Biologicals with Payments Based on Average Sales Price (ASP)
Effective January 1, 2015
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Table 6 – Other CY 2015 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2014 HCPCS/ CY 2014 Long Descriptor
CY 2015 HCPCS/ CY 2015 Long Descriptor
CPT code
CPT Code
For CY 2015, payment for nonpass-through drugs, biologicals and therapeutic
radiopharmaceuticals is made at a single rate of ASP + 6 percent, which provides
payment for both the acquisition cost and pharmacy overhead costs associated with the
drug, biological or therapeutic radiopharmaceutical. In CY 2015, a single payment of
ASP + 6 percent for pass-through drugs, biologicals and radiopharmaceuticals is made
to provide payment for both the acquisition cost and pharmacy overhead costs of these
pass-through items. Payments for drugs and biologicals based on ASPs will be updated
on a quarterly basis as later quarter ASP submissions become available.
Effective January 1, 2015, payment rates for many drugs and biologicals have changed
from the values published in the CY 2015 OPPS/ASC final rule with comment period
as a result of the new ASP calculations based on sales price submissions from the
third quarter of CY 2014. In cases where adjustments to payment rates are necessary,
changes to the payment rates will be incorporated in the January 2015 release of the
OPPS Pricer. CMS is not publishing the updated payment rates in this Change Request
implementing the January 2015 update of the OPPS. However, the updated payment
rates effective January 1, 2015, can be found in the January 2015 update of the OPPS
Addendum A and Addendum B at http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
on the CMS website.
d. Skin Substitute Procedure Edits
The payment for skin substitute products that do not qualify for pass-through status will
be packaged into the payment for the associated skin substitute application procedure.
The skin substitute products are divided into two groups: 1) high cost skin substitute
products and 2) low cost skin substitute products for packaging purposes. Table 7 lists
the skin substitute products and their assignment as either a high cost or a low cost skin
substitute product, when applicable. CMS will implement an OPPS edit that requires
hospitals to report all high-cost skin substitute products in combination with one of the
skin application procedures described by CPT codes 15271-15278 and to report all lowcost skin substitute products in combination with one of the skin application procedures
described by HCPCS codes C5271-C5278. All pass-through skin substitute products are
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Table 7 – Skin Substitute Product Assignment to High Cost/Low Cost Status for CY 2015
CY 2015 HCPCS
Code
CY 2015 Short Descriptor
CY 2015 SI
C9349
Fortaderm, fortaderm antimic
G
C9358
SurgiMend, fetal
N
C9360
SurgiMend, neonatal
N
C9363
Integra Meshed Bil Wound Mat
N
Q4100
Skin substitute, NOS
N
Q4101
Apligraf
N
Q4102
Oasis wound matrix
N
Q4103
Oasis burn matrix
N
Q4104
Integra BMWD
N
Q4105
Integra DRT
N
Q4106
Dermagraft
N
Q4107
Graftjacket
N
Q4108
Integra Matrix
N
Q4110
Primatrix
N
Q4111
Gammagraft
N
Q4112
Cymetra injectable
N
Q4113
GraftJacket Xpress
N
Q4114
Integra Flowable Wound Matrix
N
Q4115
Alloskin
N
Q4116
Alloderm
N
Q4117
Hyalomatrix
N
Q4118
Matristem Micromatrix
N
Q4119
Matristem Wound Matrix
N
Q4120
Matristem Burn Matrix
N
Q4121
Theraskin
G
Q4122
Dermacell
G
Q4123
Alloskin
N
Q4124
Oasis Tri-layer Wound Matrix
N
Q4125
Arthroflex
N
Q4126
Memoderm/derma/tranz/integup
N
Q4127
Talymed
G
Q4128
Flexhd/Allopatchhd/matrixhdNHighQ4129Unite Biomatrix N
Q4131
Epifix
N
Q4132
Grafix core
N
Q4133
Grafix prime
N
Q4134
HMatrix
N
Q4135
Mediskin
N
Q4136
EZderm
N
Q4137
Amnioexcel or Biodexcel, 1cm
N
Q4138
BioDfence DryFlex, 1cm
N
Q4139
Amniomatrix or Biodmatrix, 1cc
N
Q4140
Biodfence 1cm
N
Q4141
Alloskin ac, 1 cm
N
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Low/High Cost
Skin Substitute
High
Low
Low
High
Low
High
Low
Low
High
High
High
High
High
High
Low
N/A
N/A
N/A
Low
High
Low
N/A
Low
Low
High
High
High
Low
High
High
High
High
High
High
High
High
Low
Low
High
High
N/A
High
Low
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to be reported in combination with one of the skin application procedures described by
CPT codes 15271-15278.
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21
Low/High Cost
Skin Substitute
Low
Low
N/A
Low
High
High
Low
Low
High
Low
High
N/A
High
Low
Low
High
High
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Table 7 – Skin Substitute Product Assignment to High Cost/Low Cost Status for CY 2015
CY 2015 HCPCS
Code
CY 2015 Short Descriptor
CY 2015 SI
Q4142
Xcm biologic tiss matrix 1cm
N
Q4143
Repriza, 1cm
N
Q4145
Epifix, 1mg
N
Q4146
Tensix, 1cm
N
Q4147
Architect ecm px fx 1 sq cm
N
Q4148
Neox 1k, 1cm
N
Q4149
Excellagen, 0.1 ccNN/AQ4150Allowrap DS or Dry 1 sq cm N
Q4151
AmnioBand, Guardian 1 sq cm
N
Q4152
*Dermapure 1 square cm
N
Q4153
Dermavest 1 square cm
N
Q4154
Biovance 1 square cm
N
Q4155
NeoxFlo or ClarixFlo 1 mg
N
Q4156
Neox 100 1 square cm
N
Q4157
Revitalon 1 square cm
N
Q4158
MariGen 1 square cm
N
Q4159
Affinity 1 square cm
N
Q4160
NuShield 1 square cm
N
* HCPCS code Q4152 was assigned to the low cost group in the CY 2015 OPPS/ASC
final rule with comment period. Upon submission of updated pricing information, Q4152
is assigned to the high cost group for CY 2015.
Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates
Some drugs and biologicals based on ASP methodology will have payment rates that are
corrected retroactively. These retroactive corrections typically occur on a quarterly basis.
The list of drugs and biologicals with corrected payments rates will be accessible on
the first date of the quarter at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/index.html?redirect=/HospitalOutpatientPPS/01_
overview.asp on the CMS website. Providers may resubmit claims that were impacted by
adjustments to previous quarter’s payment files.
Changes to OPPS Pricer Logic
a. Rural sole community hospitals and Essential Access Community Hospitals
(EACHs) will continue to receive a 7.1 percent payment increase for most services
in CY 2015. The rural SCH and EACH payment adjustment excludes drugs,
biologicals, items and services paid at charges reduced to cost, and items paid
under the pass-through payment policy in accordance with Section 1833(t)(13)(B)
of the Social Security Act, as added by Section 411 of the Medicare Prescription
Drug, Improvement and Modernization Act of 2003 (MMA).
b. New OPPS payment rates and copayment amounts will be effective January 1,
2015. All copayment amounts will be limited to a maximum of 40 percent of the
APC payment rate. Copayment amounts for each service cannot exceed the CY
2014 inpatient deductible.
c. For hospital outlier payments under OPPS, there will be no change in the multiple
threshold of 1.75 for 2015. This threshold of 1.75 is multiplied by the total line-item
APC payment to determine eligibility for outlier payments. This factor also is used
to determine the outlier payment, which is 50 percent of estimated cost less 1.75
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d. The fixed-dollar threshold decreases in CY 2015 relative to CY 2014. The
estimated cost of a service must be greater than the APC payment amount plus
$2,775 in order to qualify for outlier payments.
e. For outliers for Community Mental Health Centers (bill type 76x), there will be no
change in the multiple threshold of 3.4 for 2015. This threshold of 3.4 is multiplied
by the total line-item APC payment for APC 0173 to determine eligibility for outlier
payments. This multiple amount is also used to determine the outlier payment,
which is 50 percent of estimated costs less 3.4 times the APC payment amount.
The payment formula is (cost-(APC 0173 payment x 3.4))/2.
f. Effective October 1, 2013, and continuing for CY 2015, one device is eligible
for pass-through payment in the OPPS Pricer logic. Category C1841 (Retinal
prosthesis, includes all internal and external components), has an offset amount
of $0, because CMS is not able to identify portions of the APC payment amounts
associated with the cost of the device in APC 0672, Level III, Posterior segment
eye procedures. For outlier purposes, when C1841 is billed with CPT code 0100T,
assigned to APC 0672, it will be eligible for outlier calculation and payment.
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times the APC payment amount. The payment formula is (cost-(APC payment x
1.75))/2.
g. C2624 (Implantable wireless pulmonary artery pressure sensor with delivery
catheter, including all system components), is effective January 1, 2015, device
offset is $310.33, assigned to APC 2624. The procedure this should be billed with
is C9741 (Right heart catheterization with implantation of wireless pressure sensor
in the pulmonary artery, including any type of measurement, angiography, imaging
supervision, interpretation, and report), and the procedure maps to APC 0080
(which has the offset of $310.33).
h. Effective January 1, 2015, the OPPS Pricer will apply a reduced update ratio of
0.980 to the payment and copayment for hospitals that fail to meet their hospital
outpatient quality data reporting requirements or that fail to meet CMS validation
edits. The reduced payment amount will be used to calculate outlier payments.
i.
Effective January 1, 2015, there will be two diagnostic radiopharmaceutical
receiving pass-through payment in the OPPS Pricer logic. For APCs containing
nuclear medicine procedures, Pricer will reduce the amount of the pass-through
diagnostic radiopharmaceutical payment by the wage-adjusted offset for the APC
with the highest offset amount when the radiopharmaceutical with pass-through
appears on a claim with a nuclear procedure. The offset will cease to apply when
the diagnostic radiopharmaceutical expires from pass-through status. The offset
amounts for diagnostic radiopharmaceuticals are the “policy-packaged” portions of
the CY 2014 APC payments for nuclear medicine procedures and may be found on
the CMS website.
j.
Effective January 1, 2015, there will be four skin substitute products receiving
pass-through payment in the OPPS Pricer logic. For skin substitute application
procedure codes that are assigned to APC 0328 (Level III Skin Repair) or APC
0329 (Level IV Skin Repair), Pricer will reduce the payment amount for the passthrough skin substitute product by the wage-adjusted offset for the APC when the
pass-through skin substitute product appears on a claim with a skin substitute
application procedure that maps to APC 0328 or APC 0329. The offset amounts
for skin substitute products are the “policy-packaged” portions of the CY 2014
payments for APC 0328 and APC 0329.
k. Pricer will update the payment rates for drugs, biologicals, therapeutic
radiopharmaceuticals, and diagnostic radiopharmaceuticals with pass-through
status when those payment rates are based on ASP on a quarterly basis.
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Effective January 1, 2015, CMS is adopting the FY 2015 IPPS post-reclassification
wage index values with application of out-commuting adjustment authorized by
Section 505 of the MMA to non-Inpatient Prospective Payment System (IPPS)
hospitals discussed below.
m. Effective January 1, 2015, for claims with APCs, which require implantable devices
and have significant device offsets (greater than 40%), a device offset cap will be
applied based on the credit amount listed in the “FD” (Credit Received from the
Manufacturer for a Replaced Medical Device) value code. The credit amount in
value code “FD” which reduces the APC payment for the applicable procedure, will
be capped by the device offset amount for that APC. The offset amounts for the
above referenced APCs are available on the CMS website.
n. Effective January 1, 2015, CMS is adopting the FY 2014 IPPS post-reclassification
wage index values with application of out-commuting adjustment authorized by
Section 505 of the MMA to non-IPPS hospitals discussed below.
Coverage Determinations
The fact that a drug, device, procedure or service is assigned a HCPCS code and a
payment rate under the OPPS does not imply coverage by the Medicare program, but
indicates only how the product, procedure, or service may be paid if covered by the
program. MACs determine whether a drug, device, procedure, or other service meets all
program requirements for coverage. For example, MACs determine that it is reasonable
and necessary to treat the beneficiary’s condition and whether it is excluded from
payment.
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l.
Additional Information
The official instruction, CR 9014 issued to your MAC regarding this change may be
viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/
Downloads/R3156CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health Providers
MM9051: Modifications to Medicare
Part B Coverage of Pneumococcal Vaccinations
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM9051
Related CR Release Date: December 31, 2014
Related CR Transmittal #: R202BP and R3159CP
Related Change Request (CR) #: CR 9051
Effective Date: September 19, 2014
Implementation Date: February 2, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting
claims to Medicare Administrative Contractors (MACs) for services provided to
Medicare beneficiaries.
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CR 9051 provides an update to the Medicare pneumococcal vaccine coverage
requirements, to align with new Advisory Committee on Immunization Practices (ACIP)
recommendations. Make sure your billing staffs are aware of these updates.
Background
Medicare Part B covers certain vaccinations including pneumococcal vaccines.
Specifically, Section 1861(s)(10)(A) of the Social Security Act, which is available at
http://www.ssa.gov/OP_Home/ssact/title18/1861.htm, and regulations at 42 CFR 410.57
(http://www.ecfr.gov/cgi-bin/text-idx?SID=85dbd4cb66820b751ffe58a6c58988df&node=
se42.2.410_157&rgn=div8) authorize Medicare coverage under Part B for pneumococcal
vaccine and its administration. For services furnished on or after May 1, 1981, through
September 18, 2014, the Medicare Part B program covered pneumococcal pneumonia
vaccine and its administration when furnished in compliance with any applicable State
law by any provider of services or any entity or individual with a supplier number.
Coverage included an initial vaccine administered only to persons at high risk of serious
pneumococcal disease (including all people 65 and older; immunocompetent adults at
increased risk of pneumococcal disease or its complications because of chronic illness;
and individuals with compromised immune systems), with revaccination administered
only to persons at highest risk of serious pneumococcal infection and those likely to
have a rapid decline in pneumococcal antibody levels, provided that at least 5 years had
passed since the previous dose of pneumococcal vaccine.
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Provider Action Needed
However, ACIP updated its guidelines regarding pneumococcal vaccines; now
recommending the administration of two different pneumococcal vaccinations.
CMS is updating the Medicare coverage requirements to align with the updated ACIP
recommendations. Effective for dates of service on or after September 19, 2014, (and
upon implementation of CR 9051), Medicare will cover:
yyAn initial pneumococcal vaccine to all Medicare beneficiaries who have never
received the vaccine under Medicare Part B; and
yyA different, second pneumococcal vaccine one year after the first vaccine was
administered (that is, 11 full months have passed following the month in which the
last pneumococcal vaccine was administered).
Since the updated ACIP recommendations are specific to vaccine type and sequence of
vaccination, prior pneumococcal vaccination history should be taken into consideration.
For example, if a beneficiary who is 65 years or older received the 23-valent
pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then the 13-valent
pneumococcal conjugate vaccine (PCV13) should be administered next as the second
in the series of the two recommended pneumococcal vaccinations. Receiving multiple
vaccinations of the same vaccine type is not generally recommended. Ideally, providers
should readily have access to vaccination history, such as with electronic health records,
to ensure reasonable and necessary pneumococcal vaccinations.
Medicare does not require that a doctor of medicine or osteopathy order the vaccine;
therefore, the beneficiary may receive the vaccine upon request without a physician¡¦s
order and without physician supervision.
Note that MACs will not search for and adjust any claims for pneumococcal vaccines and
their administration, with dates of service on and after September 19, 2014. However,
they may adjust such claims that you bring to their attention.
Additional Information
The official instruction, CR 9051 issued to your MAC includes two transmittals. The first
updates the “Medicare Benefit Policy Manual,” Chapter 15 (Covered Medical and Other
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The Centers for Disease Control and Prevention (CDC) recommends that providers
use two pneumococcal vaccines for adults aged >65. These vaccinations are
13-Valent Pneumococcal Conjugate Vaccine (PCV13) and 23-Valent Pneumococcal
Polysaccharide Vaccine (PPSV23). For more information on these recommendations,
visit http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm on the CDC website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Hospice Providers
Reason Code 34952:
Service Facility NPI is Required
HOME HEALTH & HOSPICE
Health Services), Section 50.4.4.2 (Immunizations) and “Medicare Claims Processing
Manual,” Chapter 18 (Preventive and Screening Services), Section 10.1.1 (Pneumococcal
Vaccine) as attachments to that transmittal. It is available at http://www.cms.gov/
Regulations-and-Guidance/Guidance/Transmittals/Downloads/R202BP.pdf on the CMS
website. The second transmittal updates the “Medicare Claims Processing Manual” and
that transmittal is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/Downloads/R3159CP.pdf on the CMS website.
CGS has identified reason code 34952 as one of the top Claim Submission Error (CSE)
errors. The reason code 34952 indicates that a service facility National Provider Identifier
(NPI) is required on the claim, but was not reported.
As a reminder, per Change Request 8358, effective for dates of service on/after April 1,
2014, hospice providers are now required to report a service facility NPI when billing any
of the following place of service HCPCS codes:
yyQ5003 – hospice care provided in nursing long term care facility (LTC) or non-skilled
nursing facility (NF)
yyQ5004 – hospice care provided in skilled nursing facility (SNF)
yyQ5005 – hospice care provided in inpatient hospital
yyQ5007 – hospice care provided in long term care hospital (LTCH)
yyQ5008 – hospice care provided in inpatient psychiatric facility
The service facility NPI must be reported in Loop 2310E (when billing in the 5010
electronic claim format) or the SERV FAC NPI field in the Fiscal Intermediary Standard
System (FISS) on Claim Page 03.
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EST AMT
DUE
A
B
C
DUE FROM PATIENT
SERV FAC NPI
MEDICAL RECORD NBR
COST RPT DAYS
NON COST RPT DAYS
DIAG CODES 01
02
03
04
05
06
07
08
09
END OF POA IND
ADMITTING DIAGNOSIS
E CODE
HOSPICE TERM ILL IND
IDE
PROCEDURE CODES AND DATES 01
02
03
04
05
06
ESRD HOURS
ADJUSTMENT REASON CODE
REJECT CODE
NONPAY CODE
ATT PHYS
NPI
L
F
M
SC
OPR PHYS
NPI
L
F
M
SC
OTH OPR
NPI
L
F
M
SC
REN PHYS
NPI
L
F
M
SC
REF PHYS
NPI
L
F
M
SC
Claims that do not include an NPI in the SERV FAC NPI field when required will be sent
to the return to provider (RTP) file (status/location T B9997) for correction. Providers can
reduce claims processing times and avoid payment delays by ensuring this information is
reported on the claim when required.
For additional information about billing hospice claims, refer to the “Hospice Claims
Filing” Web page at http://www.cgsmedicare.com/hhh/education/materials/Hospice_
CF.html on the CGS website.
For Home Health and Hospice Providers
CGS Website Updates
CGS has recently made updates to their website, giving providers additional resources to
assist with billing Medicare-covered services appropriately.
Please review the following updates:
yyThe “Medicare Hospice Benefit Facts” quick resource tool (QRT) at
http://www.cgsmedicare.com/hhh/education/materials/pdf/medicare_hospice_
benefit_facts.pdf was updated to include the requirement that hospice notices of
election (NOEs) must be submitted and accepted within 5 calendar days after the
hospice admission.
yyThe “Billing Hospice Physician and Nurse Practitioner (NP) Services” QRT
at http://www.cgsmedicare.com/hhh/education/materials/pdf/physician_and_np.pdf
was updated to add the instruction to report the “GV” modifier when billing
physician services performed by a nurse practitioner acting as the patient’s
attending physician.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-02
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FEBRUARY 2015
27
com/hhh/education/faqs/index.html) was updated to link to the “FAQs – ICD-10 Endto-End Testing” article, SE1435.
yyNEW: The new QRT, “Submitting Hospice Notices of Election (NOEs)” at
http://www.cgsmedicare.com/hhh/education/materials/pdf/submitting_noes.pdf was
developed to provide step by step instructions, including screen prints and the data
required, for submitting a hospice NOE.
yyNEW: The new Web page, “Requesting an Exception for an Untimely NOE”
at http://www.cgsmedicare.com/hhh/education/materials/requesting_exception_
untimely_noes.html was developed to provide the four exceptional circumstances
when a Notice of Election (NOE) was submitted untimely, and how to submit a claim
to request an exception.
yyThe “Discharge or Revocation of Hospice Care” Web page at http://www.
cgsmedicare.com/hhh/education/materials/discharge_or_revocation_of_hospice_
care.html was updated to indicate that a discharge may occur when the face-to-face
encounter is not done timely.
yyThe following Web pages were updated to remove instruction for entering Medicare
Secondary Payer (MSP) information via Direct Data Entry (DDE).
HOME HEALTH & HOSPICE
yyThe “Frequently Asked Questions (FAQs)” Web page (http://www.cgsmedicare.
ƒƒ
Claim Page 05 – Entering a RAP or Claim - http://www.cgsmedicare.com/hhh/
education/materials/hhe_claim_page_5.html
ƒƒ
Claim Page 06 – Entering a RAP or Claim - http://www.cgsmedicare.com/hhh/
education/materials/hhe_claim_page_6.html
ƒƒ
Claim Page 05 – Entering a Hospice Claim - http://www.cgsmedicare.com/hhh/
education/materials/claim_page_5.html
ƒƒ
Claim Page 06 – Entering a Hospice Claim - http://www.cgsmedicare.com/hhh/
education/materials/claim_page_6.html
yyThe “Claim Page 01 – Entering a Notice of Election (NOE)/Transfer NOE” Web
page at http://www.cgsmedicare.com/hhh/education/materials/claim_page_1_noe.
html was updated to remove the requirement to enter information in the HR, TYPE,
and SRC fields.
yyThe December 9, 2104, Home Health Advisory Group Meeting Minutes are now
available at: http://www.cgsmedicare.com/hhh/education/Advisory_Groups.html
yyThe “Impact of an Inpatient Admission During an HH PPS Episode” Web page
at http://www.cgsmedicare.com/hhh/education/materials/inpatient_admission_
during_hhpps_episode.html has been updated to include a link to the MM8699
article, “Preventing Duplicate Payments When Overlapping Inpatient and Home
Health (HH) Claims Are Received Out of Sequence”, as an additional Centers for
Medicare & Medicaid Services (CMS) resource.
yyThe “Transferring Beneficiary From/To Another Hospice Agency” Web page
at http://www.cgsmedicare.com/hhh/education/materials/hospice_transferring_
beneficiary.html was updated to correct the steps taken to access the CMS website
to obtain the name and address of a hospice agency.
yyThe “Submitting Paper Claims” Web page at http://www.cgsmedicare.com/hhh/
claims/Submitting_Paper_Claims.html was updated to clarify that it is necessary to
submit a paper claim when services are denied by the Federal Black Lung program.
yyThe “Untimely Face-To-Face Encounter” Web page at http://www.cgsmedicare.
com/hhh/education/materials/untimely_ftf.html has been updated to remove the
instruction to enter occurrence code 42 and the date of discharge for services prior
to June 30, 2012.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-02
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FEBRUARY 2015
28
that home health agencies (HHAs) are to submit the OASIS assessment data to
their state. Effective January 1, 2015, OASIS assessment data will be submitted
to the Centers for Medicare & Medicaid Services (CMS) via the national OASIS
Assessment Submission and Processing (ASAP) system.
ƒƒ
Home Health Denial Fact Sheet Denial Reason 5HNOA - http://www.
cgsmedicare.com/hhh/education/materials/pdf/hh_5hnoa_factsheet.pdf
ƒƒ
Outcome and Assessment Information Set (OASIS) - http://www.cgsmedicare.
com/hhh/coverage/oasis.html
ƒƒ
Home Health Billing FAQs (#15) - http://www.cgsmedicare.com/hhh/education/
faqs/hh_billing_faqs.html
yyThe Submitting Paper Claims Web page at http://www.cgsmedicare.com/hhh/
claims/Submitting_Paper_Claims.html was updated to clarify that paper claims
should be submitted when seeking Medicare payment for services denied by the
Federal Black Lung program.
yyThe Fiscal Intermediary Standard System (FISS) Guide, Chapter Two: Checking
Beneficiary Eligibility at http://www.cgsmedicare.com/hhh/education/materials/pdf/
chapter_2-checking_beneficiary_eligibility.pdf has been updated.
HOME HEALTH & HOSPICE
yyThe following CGS website resources were updated to change information indicating
For Home Health and Hospice Providers
Medicare Secondary Payer Explanation Codes
To assist in processing Medicare Secondary Payer (MSP) claims, CGS has developed
MSP Explanation Codes for providers to enter into the “Remarks” field (UB-04 Form
Locator 80). Simply enter the 2 digit code to explain the situation that applies.
The Medicare Secondary Payer Billing & Adjustments quick resource tool at http://www.
cgsmedicare.com/hhh/education/materials/pdf/msp_billing.pdf has been updated and
includes the MSP Explanation Codes that apply to specific MSP situations. A complete
list of the codes is provided on page 10. In addition, page 11 provides a list of MSP value
codes and the applicable MSP Explanation Code.
MSP Explanation Codes (Remarks FL 80)
Code Description
Applicable Value Codes
BE
Benefits are exhausted.
12, 13, 14, 15, 41, 43
CD
Charges applied to co-payment, coinsurance or deductible.
12, 13, 14, 43
DA
120 days have passed since the primary payer was billed.
14, 15, 41, 47
DP
Delay in payment from liability insurer.
47
FG
Beneficiary did not follow guidelines of their primary health plan. Use only for out
of network, untimely filing or no prior authorization. Note: Indicate which of these
guidelines was not followed.
12, 13, 15, 43
LD
Response received from liability insurer stating they are not responsible for claim.
47
NB
Not a covered benefit.
12, 13, 14, 15, 41, 43
PC
Pre-existing condition.
12, 13, 43
PE
No-Fault (also known as PIP) has been exhausted toward medical expenses.
14
PP
Beneficiary paid by liability insurer. Note: May not be used for medical payment
insurance payments to the beneficiary (VC 14). Providers are required to pursue
those dollars.
12, 13, 15, 16, 41, 43,
44, 47
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-02
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FEBRUARY 2015
29
MM8901: Incorporation of Certain Provider
Enrollment Policies in CMS-4159-F into Pub. 10008, Program Integrity Manual (PIM), Chapter 15
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8901
Related CR Release Date: December 12, 2014
Related CR Transmittal #: R561PI
Related Change Request (CR) #: CR 8901
Effective Date: March 18, 2015
Implementation Date: March 18, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians and eligible professionals who
prescribe Medicare Part D drugs, and for providers and suppliers that submit claims
to Medicare Administrative Contractors (MACs) for services provided to Medicare
beneficiaries.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
What You Need to Know
CR 8901 incorporates into Chapter 15 of the “Program Integrity Manual” (PIM) several
provider enrollment policies in the final rule titled, “Medicare Program; Contract Year
2015 Policy and Technical Changes to the Medicare Advantage and the Medicare
Prescription Drug Benefit Programs.”
Key Points of CR 8901
The key points of the updated Chapter 15 of the “Medicare Program Integrity Manual” are
as follows:
yyIf a MAC approves a provider’s or supplier’s Form CMS-855 reactivation application
or Reactivation Certification Package (RCP) for a Part B non-certified supplier, the
reactivation effective date will be the date the MAC received the application or RCP
that was processed to completion. Also, upon reactivating billing privileges for a
Part B non-certified supplier, the MAC will issue a new Provider Transaction Access
Number (PTAN).
yyCMS may deny a physician’s or eligible professional’s Form CMS-855 enrollment
application under § 424.530(a)(11) if:
ƒƒ
The physician’s or eligible professional’s Drug Enforcement Administration (DEA)
Certificate of Registration to dispense a controlled substance is
currently suspended or revoked; or
ƒƒ
The applicable licensing or administrative body for any state in which the physician
or eligible professional practices has suspended or revoked the physician’s or
eligible professional’s ability to prescribe drugs, and such suspension or revocation
is in effect on the date the physician or eligible professional submits his or her
enrollment application to the Medicare contractor.
yyCMS may revoke a physician’s or eligible professional’s Medicare enrollment under §
424.535(a)(13) if:
ƒƒ
The physician’s or eligible professional’s DEA Certificate of Registration is
suspended or revoked; or
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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30
yyCMS may revoke a physician’s or eligible professional’s Medicare enrollment
under § 424.535(a)(14) if CMS determines that the physician or eligible
professional has a pattern or practice of prescribing Part D drugs that falls
into one of the following categories:
ƒƒ
The pattern or practice is abusive or represents a threat to the health and safety of
Medicare beneficiaries or both.
ƒƒ
The pattern or practice of prescribing fails to meet Medicare requirements.
Additional Information
The official instruction, CR8901, issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R561PI.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
HOME HEALTH & HOSPICE
ƒƒ
The applicable licensing or administrative body for any state in which the physician
or eligible professional practices has suspended or revoked the physician’s or
eligible professional’s ability to prescribe drugs.
For Home Health and Hospice Providers
MM9005: January 2015 Integrated Outpatient
Code Editor (I/OCE) Specifications Version 16.0
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM9005
Related CR Release Date: December 19, 2014
Related CR Transmittal #: R3135CP
Related Change Request (CR) #: CR 9005
Effective Date: January 1, 2015
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers
submitting claims to Medicare Administrative Contractors (MACs) for outpatient
services provided to Medicare beneficiaries and paid under the Outpatient Prospective
Payment System (OPPS) and for outpatient claims from any non-OPPS provider not paid
under the OPPS, and for claims for limited services when provided in a Home Health
Agency (HHA) not under the Home Health Prospective Payment System (HH PPS) or
claims for services to a hospice patient for the treatment of a non-terminal illness.
Provider Action Needed
This article is based on CR 9005 which informs MACs about the changes to the
Integrated Outpatient Code Editor (I/OCE) instructions and specifications for the
Integrated OCE that will be utilized under the OPPS and Non-OPPS for hospital
outpatient departments, community mental health centers, all non-OPPS providers,
and for limited services when provided in a home health agency not under the Home
Health Prospective Payment System or to a hospice patient for the treatment of a nonterminal illness. Make sure that your billing staffs are aware of these changes.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-02
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FEBRUARY 2015
31
CR 9005 instruction informs the MACs and the Fiscal Intermediary Shared
System (FISS) that the I/OCE is being updated for January 1, 2015. The I/OCE
routes all institutional outpatient claims (which includes non-OPPS hospital claims)
through a single integrated OCE, which eliminates the need to update, install, and
maintain two separate OCE software packages on a quarterly basis. The full list of
I/OCE specifications can now be found at http://www.cms.gov/Medicare/Coding/
OutpatientCodeEdit/index.html on the CMS website. There is a summary of the changes
for January 2015 in Appendix O (located in Appendixes M or N of prior releases) of
Attachment A of CR 9005 and that summary is captured in the following table.
Summary of Modifications
Effective Edits
Type
Date
Affected Modification
Logic
1/1/2015 24
Modify the software to maintain 28 prior quarters (7 years) of programs in each release.
Remove older versions with each release. (The earliest version date included in this
January 2015 release is 4/1/2008)
Logic
1/1/2015
Status Indicator (SI) changes:
yy­New SI - J1 (Hospital Part B services paid through a comprehensive APC)
yy­Deactivate SI X
Modify description for SI Q1 to remove reference to SI X (STV – Packaged Codes)
Logic
1/1/2015 92
Implement new edit 92 (Device-dependent procedure reported without device code)
Edit criteria:
yyA device-dependent procedure is reported without a device code - Return
to Provider (RTP)
Logic
1/1/2015
Implement Comprehensive Ambulatory Payment Classification (APC)
logic (new Appendix L):
yySpecified device-dependent procedures (SI = J1) are assigned
to a comprehensive APC
yyMultiple J1 procedures may be subject to a complexity adjustment which assigns a
different comprehensive APC
yyPackage all other procedures (change the SI to N) present on the same claim, with
exceptions for services that are not covered under OPPS (SI = B, E, M) and services
that are excluded by statute
Logic
1/1/2015
Add new payment adjustment flag value 11 (Multiple units of service present paid at single
comprehensive APC rate) and update Appendix G to include new value.
Logic
1/1/2015
Updates to Appendix F(a) for January 2015:
yyAdd edit 86 for home health bill type 32x
yyAdd new edit 92 for applicable bill types
Logic
1/1/2014
Update Appendix F(a): Remove edits 61 and 72 from hospice bill types (81x, 82x), effective
retroactively to 1/1/2014.
Logic
1/1/2015 71, 77
Deactivate edits 71 and 77 (procedure/device; device/procedure).
Logic
1/1/2015
Deactivate special logic for CRT-D (Cardioverter Defibrillator with Pacing Electrode)
which conditionally packaged procedure 33225 with 33249.
Logic
1/1/2015 84
Remove code pairs associated with 33225 from the edit logic for edit 84.
Logic
1/1/2015
Revise program logic to remove reference to SI X from conditional
packaging (STVX-packaging).
Logic
1/1/2015
Updates to Appendix K on page 39 to note the deactivation of composite APC 8000.
Logic
1/1/2015 8
Update to the sex conflict list by adding codes 0357T and 89337 to the female only list.
Logic
10/1/2014
Modify the Federally Qualified Health Clinic (FQHC) PPS logic to ignore modifier 59 when
reported with an established patient mental health visit (G0469).
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-02
HOME HEALTH & HOSPICE
Background
RETURN TO
TABLE OF CONTENTS
FEBRUARY 2015
32
PO: Serv/proc off-campus pbd
XE: Separate Encounter
XP: Separate Practitioner
XS: Separate Structure
XU: Unusual Non-Overlapping Service
Logic
Logic
Logic
Logic
Logic
Content
Content
Doc
1/1/2015
1/1/2015
6/2/2014
1/9/2014
8/1/2014
1/1/2015
1/1/2015
1/1/2015
Doc
Doc
Doc
1/1/2015
1/1/2015
1/1/2015
Doc
10/1/2014
Other
1/1/2015
Other
1/1/2015
75
87
68
68
67
20, 40
Note: XE, XP, XS, XU are designated as National Correct Coding
Initiative (NCCI) modifiers
Edit 75 (Incorrect billing of modifier FB or FC) is deactivated.
Updated skin substitute product lists (Lists A and B in Appendix P).
Implement mid-quarter approval for G0472.
Implement mid-quarter approval for G0276.
Implement mid-quarter approval for 90687.
Make HCPCS/APC/SI changes as specified by CMS (data change files).
Implement version 21.0 of the NCCI (as modified for applicable institutional providers).
Rename Appendices from Appendix L forward, to accommodate new Comprehensive
APC Processing Logic (new Appendix L); Appendix M
yyFQHC Processing, Appendix N: OCE Overview, Appendix O: Summary of
Modifications, Appendix P: Code Lists.
Update to Appendix D to include notes regarding modifier 50 and comprehensive APCs.
Update Appendix E (Payment Method Flag) to add SI = J1 and note deactivation of SI = X.
Updated IOCE specification document to remove any reference to Fiscal Intermediary or
“FI” (includes edit descriptions for edits 11 and 72, and any field description that included a
reference to FI/MAC).
Updates related to FQHC PPS:
yyCorrect the output buffer placement of edit 90 from the Procedure Edits Buffer
to the Revenue Edits Buffer (only a change to IOCE output placement in the
mainframe software)
yyAdded documentation to the specifications regarding bill type 770 (no payment
claim), all claim lines are assigned line item action flag 5 but edit 91 is not returned
(Appendix M)
yyAdded documentation to the specifications regarding the use of SI of E for FQHC
non-covered services (Appendix M)
Create 508-compliant versions of the specifications & Summary of Data Changes
documents for publication on the CMS web site.
Deliver quarterly software update & all related documentation and files to users via
electronic means.
HOME HEALTH & HOSPICE
Summary of Modifications
Effective Edits
Type
Date
Affected Modification
Logic
10/1/2014
Update the following for FQHC PPS:yyAdd HCPCS Q0091 as a qualifying visit code for new and established patient visits
yyAdd HCPCS G0472 as a preventive serviceyyRemove HCPCS M0064 from qualifying visit code pair (Appendix M) for G0467; code
is deleted.
Logic
1/1/2015 22
Add new modifiers to the valid modifier list:
Additional Information
The official instruction, CR 9005 issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R3153CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-02
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FEBRUARY 2015
33
MM9034: Summary of Policies in the
Calendar Year (CY) 2015 Medicare Physician
Fee Schedule (MPFS) Final Rule and Telehealth
Originating Site Facility Fee Payment Amount
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM9034
Related CR Release Date: December 24, 2014
Related CR Transmittal #: R3157CP
Related Change Request (CR) #: CR 9034
Effective Date: January 1, 2015
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers who submit
claims to Medicare Administrative Contractors (MACs) for services provided to Medicare
beneficiaries.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
Provider Action Needed
This article is based on CR 9034 which provides a summary of the policies in the CY
2015 MPFS Final Rule and announces the Telehealth Originating Site Facility Fee
payment amount. Make sure that your billing staff are aware of these updates for 2015.
Background
The Social Security Act (Section 1848(b)(1); (see http://www.ssa.gov/OP_Home/
ssact/title18/1848.htm on the Internet) requires CMS to establish a fee schedule of
payment amounts for physicians’ services for the subsequent year. CMS issued a final
rule with comment period on October 13, 2014 (see https://www.federalregister.gov/
articles/2014/11/13 on the Internet), that updates payment policies and Medicare payment
rates for services furnished by physicians and non-physician practitioners (NPPs) that
are paid under the MPFS in CY 2015.
The final rule also addresses public comments on Medicare payment policies that
were described in the proposed rule earlier this year: “Medicare Program; Revisions to
Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule,
Access to Identifiable Data for the Center for Medicare & Medicaid Innovation Models
& Other Revisions to Part B for CY 2015; Proposed Rule” was published in the Federal
Register on July 11, 2014. (See http://www.gpo.gov/fdsys/pkg/FR-2014-07-11/pdf/201415948.pdf on the Internet).
The final rule also addresses interim final values established in the CY 2014 MPFS final
rule with comment period. (See http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/201328737.pdf on the Internet). The final rule assigns interim final values for new, revised, and
potentially misvalued codes for CY 2015 and requests comments on these values. CMS
will accept comments on those items open to comment in the final rule with comment
period until December 30, 2014.
Sustainable Growth Rate (SGR)
The Protecting Access to Medicare Act of 2014 (see http://www.gpo.gov/fdsys/pkg/
BILLS-113hr4302enr/pdf/BILLS-113hr4302enr.pdf on the Internet) provides for a zero
percent update from the CY 2014 rates for services furnished between January 1, 2015,
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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FEBRUARY 2015
34
Under current law, the conversion factor will be adjusted on April 1, 2015. In the
final rule CMS announced a conversion factor of $28.2239 for this period, resulting in an
average reduction of 21.2 percent from the CY 2014 rates. In most prior years, Congress
has taken action to avert large across-the-board reductions in PFS rates before they
went into effect. The Administration supports legislation to permanently change SGR to
provide more stability for Medicare beneficiaries and providers while promoting efficient,
high quality care.
Screening and Diagnostic Digital Mammography
To ensure that the higher resources needed for 3D mammography are recognized,
Medicare will pay for 3D mammography using add-on codes that will be reported in
addition to the 2D mammography codes when 3D mammography is furnished. See
MLN Matters® Article MM8874 at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8874.pdf
for more information.
Primary Care and Chronic Care Management
HOME HEALTH & HOSPICE
and March 31, 2015. Adjusting by .06 percent to achieve required budget neutrality, the
conversion factor for this period is $35.8013.
Medicare continues to emphasize primary care by making payment for chronic care
management (CCM) services — non-face-to-face services to Medicare beneficiaries
who have two or more chronic conditions — beginning January 1, 2015. CCM services
include regular development and revision of a plan of care, communication with other
treating health professionals, and medication management. CCM can be billed once per
month per qualified beneficiary, provided the minimum level of services is furnished.
CMS is finalizing its proposal to allow greater flexibility in the supervision of clinical staff
providing CCM services. The proposed application of the “incident to” supervision rules
was widely supported by the commenters.
Payment for CCM is only one part of a multi-faceted CMS initiative to improve Medicare
beneficiaries’ access to primary care. Models being tested through the Innovation Center
will continue to explore other primary care innovations.
Finally, CMS will require that in order to bill CCM, a practitioner must use a certified
electronic health record (EHR) that meets the requirements for the EHR Incentive
Program as of December 31 of the prior calendar year.
Application of Beneficiary Cost Sharing To
Anesthesia Related To Screening Colonoscopies
The Medicare statute waives the Part B deductible and coinsurance applicable to
screening colonoscopy. In the CY 2015 final rule, CMS revised the definition of a
“screening colonoscopy” to include separately provided anesthesia as part of the
screening service so that the coinsurance and deductible do not apply to anesthesia
for a screening colonoscopy, reducing beneficiaries’ cost-sharing obligations under
Part B. For more information, review MLN Matters® Article MM8874 at http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
Downloads/MM8874.pdf on the CMS website.
Enhanced Transparency in Setting PFS Rates
Since the beginning of the physician fee schedule in 1992, CMS adopted rates for new
and revised codes for the following calendar year in the final rule on an interim basis
subject to public comment. This policy was necessary because CMS did not receive the
codes in time to include in the PFS proposed rule. Until recently, the only services that
were affected by this policy were services with new and revised codes. In recent years,
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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35
Potentially Misvalued Services
Consistent with amendments to the Affordable Care Act (see http://www.gpo.gov/
fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf on the Internet), CMS has been
engaged in a vigorous effort over the past several years to identify and review potentially
misvalued codes, and to make adjustments where appropriate.
The following are major misvalued code decisions for 2015:
yyRadiation Therapy and Gastroenterology: Consistent with the final rule policy
and in response to public comments, CMS is not adopting the CPT coding changes
for CY 2015 for gastroenterology and radiation therapy services so that CMS can
propose and obtain comments on the revised coding prior to using them for payment.
As a result, CMS will not recognize some new CPT codes, and created G-codes in
place of changed and new CPT codes.
HOME HEALTH & HOSPICE
CMS began receiving new and revised codes and revaluing existing services under the
misvalued codes initiative. Establishing payment in the final rule for misvalued codes
often led to implementation of payment reductions before the public had the opportunity
to comment. CMS finalized its proposal to change the process for valuing new, revised
and potentially misvalued codes for CY 2016, so that payment for the vast majority of
these codes goes through notice and comment rulemaking prior to being adopted. After
a transition in CY 2016, the process will be fully implemented in CY 2017.
yyRadiation Treatment Vault: CMS proposed to refine the way it accounts for the
infrastructure costs associated with radiation therapy equipment, specifically to
remove the radiation treatment vault as a direct expense when valuing radiation
therapy services. After considering public comments, CMS did not finalize this
proposal.
yyEpidural Pain Injections: CMS reduced payment for these services in 2014 under
the misvalued code initiative. In response to concerns from pain physicians regarding
the accuracy of the valuation, CMS proposed to raise the values in 2015 based on
their prior resource inputs before adopting further changes after considering RUC
recommendations. However, because the inputs for these services included those
related to image guidance, CMS also proposed to prohibit separate billing for image
guidance for CY 2015. CMS finalized the policy as proposed to avoid duplicate
payment for image guidance. CMS has asked the RUC to further review this issue
and make recommendations to us on how to value epidural pain injections.
yyFilm to Digital Substitution: CMS finalized its proposal to update the practice
expense inputs for X-ray services to reflect that X-rays are currently done digitally
rather than with analog film.
Global Surgery
The U.S. Department of Health and Human Services (HHS), Office of Inspector
General (OIG) has identified a number of surgical procedures that include more visits
in the global period than are being furnished. CMS is also concerned that post-surgical
visits are valued higher than visits that were furnished and billed separately by other
physicians such as general internists or family physicians.
CMS finalized a proposal to transform all 10- day and 90-day globals to 0-day globals,
beginning with 10-day global services in CY 2017 and following with the 90-day global
services in 2018. As CMS revalues these services as 0-day global periods, CMS will
actively assess whether there is a better construction of a bundled payment for surgical
services that incentivizes care coordination and care redesign across an episode of care.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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36
CMS is adding the following services to the list of services that can be furnished to
Medicare beneficiaries under the telehealth benefit:
yyAnnual wellness visits,
yyPsychoanalysis,
yyPsychotherapy, and
yyProlonged evaluation and management services.
For the list of telehealth services, visit: http://www.cms.gov/Medicare/Medicare-GeneralInformation/Telehealth/index.html on the CMS website.
Telehealth Origination Site Facility Fee Payment Amount Update
The Social Security Act (Section 1834(m)(2)(B) (see http://www.ssa.gov/OP_Home/ssact/
title18/1834.htm) establishes the payment amount for the Medicare telehealth originating
site facility fee for telehealth services provided from October 1, 2001, through December
31 2002, at $20.
For telehealth services provided on or after January 1 of each subsequent calendar year,
the telehealth originating site facility fee is increased by the percentage increase in the
Medicare Economic Index (MEI) as defined in the Social Security Act (Section 1842(i)(3)
(see http://www.ssa.gov/OP_Home/ssact/title18/1842.htm on the Internet).
HOME HEALTH & HOSPICE
Access to Telehealth Services
The MEI increase for 2015 is 0.8 percent. Therefore, for CY 2015, the payment amount
for HCPCS code Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser
of the actual charge, or $24.83. (The beneficiary is responsible for any unmet deductible
amount and Medicare coinsurance.)
Revisions to Malpractice Relative Value Units (RVUs)
As required by the Medicare law, CMS conducted a five-year review and updated the
resource-based malpractice RVUs based on updated professional liability insurance
premiums, largely paralleling the methodology used in the CY 2010 update. The final rule
indicated that anesthesia RVUs will be updated in CY 2016.
Revisions to Geographic Practice Cost Indices (GPCIs)
As required by the Medicare law, CMS adjusts payments under the PFS to reflect local
differences in the cost of operating a medical practice. For CY 2015, CMS is using
territory-level wage data to calculate the work GPCI and employee wage component of
the PE GPCI for the Virgin Islands.
The CY 2015 GPCIs also reflect the application of the statutorily mandated of 1.5 work
GPCI floor in Alaska, and 1.0 work GPCI floor for all other physician fee schedule areas,
and the 1.0 PE GPCI floor for frontier states (Montana, Nevada, North Dakota, South
Dakota, and Wyoming).
However, given that the statutory 1.0 work GPCI floor is scheduled to expire under
current law on March 31, 2015, the GPCIs reflect the elimination of the 1.0 work GPCI
floor from April 1, 2015, through December 31, 2015.
Services Performed in Off-campus Provider-Based Departments
CMS will collect data on services furnished in off-campus provider-based departments
by requiring hospitals to report a modifier for those services furnished in an off-campus
provider-based department of the hospital and by requiring physicians and other
billing practitioners to report these services using a new place of service code on
professional claims.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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Additional Information
The official instruction, CR 9034, issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R3157CP.pdf on the CMS website.
For more information about the EHR Program, go to http://www.cms.gov/Regulationsand-Guidance/Legislation/EHRIncentivePrograms/index.html on the CMS website.
The final rule, published on November 13, 2014, is available at http://www.gpo.gov/fdsys/
pkg/FR-2014-11-13/pdf/2014-26183.pdf on the Internet.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
MLN Connects™ Provider eNews
HOME HEALTH & HOSPICE
Data collection will be voluntary for hospitals in 2015 and required beginning on January
1, 2016. The new place of service codes will be used for professional claims as soon as
it is available, but not before January 1, 2016.
The MLN Connects™ Provider eNews contains a weeks worth of Medicare-related
messages issued by the Centers of Medicare & Medicaid Services (CMS). These
messages ensure planned, coordinated messages are delivered timely about Medicarerelated topics. The following provides access to the weekly messages. Please share with
appropriate staff. If you wish to receive the listserv directly from CMS, please contact
CMS at [email protected].
yyDecember 18, 2014 - http://www.cms.gov/Outreach-and-Education/Outreach/
FFSProvPartProg/Downloads/2014-12-18-eNews.pdf
yyJanuary 8, 2015 - http://www.cms.gov/Outreach-and-Education/Outreach/
FFSProvPartProg/Downloads/2015-01-08-eNews.pdf
yyJanuary 15, 2015 - http://www.cms.gov/Outreach-and-Education/Outreach/
FFSProvPartProg/Downloads/2015-01-15-Enews.pdf
For Home Health and Hospice Providers
News Flash Messages from the Centers
for Medicare & Medicaid Services (CMS)
yySubscribe to the MLN Connects™ Provider eNews at https://public.govdelivery.
com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7819: a weekly
electronic publication with the latest Medicare program information, including MLN
Connects™ National Provider Call announcements, claim and PRICER information,
and Medicare Learning Network® educational product updates.
yyNEW “Reading the Institutional Remittance Advice” Booklet, ICN 908326,
downloadable - http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/Downloads/Institutional-RA-Booklet-ICN908326.pdf
yyMLN Matters ® Articles Index: Have you ever tried to search MLN Matters ® articles
for information regarding a certain issue, but you did not know what year it was
published? To assist you next time in your search, try the CMS article indexes that
are published at http://www.cms.gov/outreach-and-education/medicare-learningThis newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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38
yyREVISED “Medicaid Program Integrity: Preventing Provider Medical Identity Theft”
Fact Sheet, ICN 908265, Downloadable - http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Med-IDTheft-FactSheet-ICN908265.pdf
yyWant to stay connected about the latest new and revised Medicare Learning
Network® (MLN) products and services? Subscribe to the MLN Educational Products
electronic mailing list! For more information about the MLN and how to register for
this service, visit http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/MLNProducts_listserv.pdf and start
receiving updates immediately!
yyREVISED “Medicare Enrollment and Claim Submission Guidelines” Booklet (ICN
906764), Hard copy - http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/MedicareClaimSubmissionGuideli
nes-ICN906764.pdf
HOME HEALTH & HOSPICE
network-mln/MLNMattersArticles/ on the CMS website. These indexes resemble
the index in the back of a book and contain keywords found in the articles, including
HCPCS codes and modifiers. These are published every month. Just search for a
keyword(s) and you will find articles that contain those word(s). Then just click on one
of the related article numbers and it will open that document. Give it a try.
yyNEW “Complying With Medical Record Documentation Requirements” Fact Sheet,
ICN 909160, Downloadable - http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDocFactSheet-ICN909160.pdf
yyREVISED “Safeguarding Your Medical Identity” Web-based Training (WBT) -
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/WebBasedTraining.html
For Home Health and Hospice Providers
Provider Contact Center (PCC) Availability
Medicare is a continuously changing program, and it is important that we provide correct
and accurate answers to your questions. To better serve the provider community, the
Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers
the opportunity to offer training to our customer service representatives (CSRs). The list
below indicates when the home health and hospice PCC at 1.877.299.4500 (option 1) will
be closed for training.
Date
February 16, 2015, President’s Day
PCC Closed
8:00 a.m. – 4:30 p.m. Central Time
The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in
obtaining patient eligibility information, claim and deductible information, and general
information. For information about the IVR, access the IVR User Guide at http://www.
cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition,
CGS’ Internet portal, myCGS, is available to access eligibility information through the
Internet. For additional information, go to http://www.cgsmedicare.com/hhh/index.html
and click the “myCGS” button on the left side of the Web page.
For your reference, access the “Home Health & Hospice 2015 Holiday/Training
Closure Schedule” at http://www.cgsmedicare.com/hhh/help/pdf/2015_holiday_
schedule.pdf for a complete list of PCC closures.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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Quarterly Provider Update
The Quarterly Provider Update is a comprehensive resource published by the Centers
for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a
listing of all nonregulatory changes to Medicare including transmittals, manual changes,
and any other instructions that could affect providers. Regulations and instructions
published in the previous quarter are also included in the update. The purpose of the
Quarterly Provider Update is to:
yyInform providers about new developments in the Medicare program;
yyAssist providers in understanding CMS programs and complying with Medicare
regulations and instructions;
yyEnsure that providers have time to react and prepare for new requirements;
yyAnnounce new or changing Medicare requirements on a predictable schedule; and
yyCommunicate the specific days that CMS business will be published in the
Federal Register.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
To receive notification when regulations and program instructions are added throughout
the quarter, go to https://www.cms.gov/Regulations-and-Guidance/Regulations-andPolicies/QuarterlyProviderUpdates/CMS-Quarterly-Provider-Updates-Email-Updates.
html to sign up for the Quarterly Provider Update (electronic mailing list).
We encourage you to bookmark the Quarterly Provider Update website at
https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/
QuarterlyProviderUpdates/index.html and visit it often for this valuable information.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
SE1435 (Revised): FAQs – International
Classification of Diseases, 10th Edition (ICD-10)
End-to-End Testing
The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning
Network® (MLN) Matters article on December 12, 2014. CMS then issued a revision to this article on
December 24, 2014. The following reflects the revised article. This MLN Matters article and other CMS
articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html
MLN Matters® Number: SE1435 Revised
Related CR Release Date: N/A
Related CR Transmittal #: N/A
Related Change Request (CR) #: N/A
Effective Date: N/A
Implementation Date: N/A
Note: This article was revised on December 24, 2014, to add FAQs 6-8 on page 3 and the former FAQ 6 is
now FAQ 9. All other information remains the same.
Provider Types Affected
This MLN Matters® Special Edition article is intended for all physicians, providers,
suppliers, clearinghouses, and billing agencies selected to participate in Medicare
ICD-10 end-to-end testing.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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Physicians, providers, suppliers, clearinghouses, and billing agencies selected to
participate in Medicare ICD-10 end-to-end testing should review the following questions
and answers before preparing claims for ICD-10 end-to-end testing to gain an
understanding of the guidelines and requirements for successful testing.
What to Know Prior to Testing
1. How is ICD-10 end-to-end testing different from acknowledgement testing?
The goal of acknowledgement testing is for testers to submit claims with
ICD-10 codes to the Medicare Fee-For-Service claims systems and receive
acknowledgements to confirm that their claims were accepted or rejected.
End-to-end testing takes that a step further, processing claims through all Medicare
system edits to produce and return an accurate Electronic Remittance Advice (ERA).
While acknowledgement testing is open to all electronic submitters, end-to-end
testing is limited to a smaller sample of submitters who volunteer and are selected
for testing.
2. What constitutes a testing slot for this testing?
A testing slot is the ability to submit 50 claims to a particular Medicare Administrative
Contractor (MAC) who selected you for testing.
HOME HEALTH & HOSPICE
Provider Action Needed
3. What data must I provide to the MAC before testing?
For each testing slot, you must provide the MAC: up to 2 submitter
identifiers (IDs), up to 5 National Provider Identifiers (NPIs)/Provider Transaction
Access Numbers (PTANs), and up to 10 Health Insurance Claim Numbers (HICNs).
You may use these in any combination on the 50 claims. You will need to use the
same HICN on multiple claims. Therefore, you will need to consider this when
designing a test plan, since claims will be subject to standard utilization edits.
If you were selected to test with only one submitter ID but would like to choose a
second one, you must contact the MAC to add the second submitter ID. If the MAC
is not aware of your preference to use a second submitter ID, claims submitted with
that ID may not be processed.
4. What should I consider when choosing HICNs for testing?
The MAC will copy production information into the test region for the HICNs that you
provide. This includes eligibility information, claims history, and other documentation
such as Certificates of Medical Necessity (CMNs). The HICNs you provide must
be real beneficiaries and may not have a Date of Death on file. If you previously
submitted HICNs for beneficiaries who are deceased, contact the MAC as soon as
possible with replacement HICNs.
5. If I was selected for the January 2015 end-to-end testing, do I need to reapply
for later testing rounds?
No, once you are selected for testing, you are automatically registered for the later
rounds of testing.
6. Does this mean that no new submitters will be accepted for the April and July
2015 end-to-end testing periods or will a new group of 850 testers be selected
for both April and July?
A new group will be selected for each of the April and July 2015 testing periods,
and these groups will be able to test in addition to the already chosen testers.
Therefore, the total number of potential testers will be 1,700 for April 2015
and 2,550 for July 2015.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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We will release this information as part of the public release of our January
test results.
8. When do you expect to publically release results of the first round
of end-to-end testing?
We expect to publically release results of the first round of end-to-end testing around
the end of February 2015.
9. Can I submit additional NPIs, PTANs, and HICNs for the later rounds
of testing?
Yes, while you do not need to re-apply for the later rounds of testing, you may
choose to submit up to 2 additional submitter IDs, up to 5 additional NPIs/PTANs,
and up to 10 additional HICNs. You may also still use the information you submitted
for the previous testing round. The MAC will provide the form you must use to submit
this new information, and the information must be received by the due date on the
form to be considered for the next round of testing.
What to Know During Testing
HOME HEALTH & HOSPICE
7. Do you have information on who has been selected for the January 2015
end-to-end testing?
1. Is it safe to submit test claims with Protected Health Information (PHI)?
The test claims you submit are accepted into the system using the same secure
method used for production claims on a daily basis. They will be processed by the
same MACs who process production claims, and all the same security protocols will
be followed. Therefore, using real data for this test does not cause any additional risk
of release of PHI.
2. What Dates of Service can be used on test claims?
Professional claims with an ICD-10 code must have a date of service on or after
October 1, 2015.
Inpatient claims with an ICD-10 code must have a discharge date on or after October
1, 2015.
Supplier claims with an ICD-10 code must have a date of service between October 1,
2015, and October 15, 2015.
For professional and institutional claims, you may use dates up to December 31,
2015. You cannot use dates in 2016 or beyond.
3. Can both ICD-9 and ICD-10 codes be submitted on the same claim?
ICD-9 and ICD-10 codes cannot be submitted on the same claim. For additional
information on how to submit claims that span the ICD-10 implementation date (when
ICD-9 codes are effective for that portion of the services rendered on September
30, 2015, and earlier, and when ICD-10 codes are effective for that portion of the
services rendered on October 1, 2015, and later), please refer to MLN Matters®
Article SE1325, “Institutional Services Split Claims Billing Instructions for Medicare
Fee-For-Service (FFS) Claims that span the ICD-10 Implementation Date” located
at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/SE1325.pdf on the CMS website.
4. Do Returned to Provider (RTP) claims count toward the 50 claims submitted?
Can RTP’d claims be re-submitted for testing?
Institutional claims that fail Return to Provider (RTP) editing count toward the 50
claim submission limit. Claims that are RTP’d will not appear on the electronic
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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42
Claims that are rejected by front end editing do not count toward the 50 claim
submission limit; therefore, they should be corrected and resubmitted.
5. If a Certificate of Medical Necessity (CMN) or DME Information Form (DIF) is
required for a supplier claim, do I need to submit a CMN during testing?
If the beneficiary has a valid CMN or DIF on file for that equipment/supply covered
by the dates of service on your test claim (after 10/1/2015), you do not need to submit
a new CMN/DIF.
If the beneficiary’s CMN/DIF has expired for the dates of service on your test claim
(after 10/1/2015), you must submit a revised CMN/DIF to extend the end date for that
CMN/DIF.
If the beneficiary does not have a CMN or DIF for that equipment/supply, you must
submit a new CMN/DIF.
6. For Home Health claims, how should I submit the Request for Anticipated
Payment (RAP) and final claim for testing?
HOME HEALTH & HOSPICE
remittance advice, and will not be available through DDE. If claims accepted by the
front end edits do not appear on the remittance advice, please contact the Medicare
Administrative Contractor (MAC) for further information.
Submit the RAP and final claim in the same file and the system will allow them to
process. The final claim will be held and recycle (as in normal processing) until the
RAP finalizes. It will then be released to the Common Working File (CWF). The RAP
processing time will be short since the test beneficiaries are set up in advance.
To get your results more quickly, you may also want to consider billing Low Utilization
Payment Adjustment claims with four visits or less that do not require a RAP.
7. For Hospice claims, should I submit the Notice of Election (NOE) prior
to testing?
You will not need to provide NOEs to the MAC prior to the start of testing. The MACs
will set up NOEs for any hospice claims received during testing.
8. For an Inpatient Rehabilitation Facility (IRF) or Skilled Nursing Facility (SNF)
stay, can the Case-Mix Group (CMG) or Resource Utilization Group (RUG)
code be submitted on the claim even though the date of service is in
the future?
Yes, you can send the IRF claim with a valid CMG code on the claim and a SNF
claim with a valid RUG code on the claim, even though the date is in the future. For
testing purposes, only a claim with a valid Health Insurance Prospective Payment
System (HIPPS) code will be required. You do not need to submit the supporting
data sheets.
Additional Information
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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FEBRUARY 2015
43
SE1501: FAQs – International Classification of
Diseases, 10th Edition (ICD-10) Acknowledgement
Testing and End-to-End Testing
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: SE1501
Related CR Release Date: N/A
Related CR Transmittal #: N/A
Related Change Request (CR) #: N/A
Effective Date: N/A
Implementation Date: N/A
Provider Types Affected
This MLN Matters® Special Edition article is intended for all physicians, providers,
suppliers, clearinghouses, and billing agencies who participate in Medicare ICD-10
acknowledgement testing and who are selected to participate in end-to-end testing.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
Provider Action Needed
Physicians, providers, suppliers, clearinghouses, and billing agencies who participate
in acknowledgement testing and who are selected to participate in Medicare ICD10 end-to-end testing should review the following questions and answers before
preparing claims for ICD-10 acknowledgement testing and end-to-end testing to gain an
understanding of the guidelines and requirements for successful testing. When “you” is
used in this publication, we are referring to ICD-10 acknowledgement testers or end-toend testers.
Question
Do I need to register for
testing?
Acknowledgement Testing
No, you do not need to register for
acknowledgement testing.
Who can participate in
testing?
Acknowledgement testing is open to
all Medicare Fee-For-Service (FFS)
electronic submitters.
How many testers will be
selected?
All Medicare FFS electronic submitters
can acknowledgement test.
End-to-End Testing
Yes, end-to-end testing volunteers must register
on their Medicare Administrative Contractor
(MAC) website during specific time periods.
End-to-end testing is open to:
yyMedicare FFS direct submitters;
yyDirect Data Entry (DDE) submitters who
receive an Electronic Remittance Advice
(ERA);
yyClearinghouses; and
yyBilling agencies.
50 end-to-end testers will be selected per MAC
jurisdiction for each testing round. You must be
selected by the MAC for this testing.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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Acknowledgement Testing
End-to-End Testing
The goal of acknowledgement testing is The goal of end-to-end testing is to
to demonstrate that:
demonstrate that:
yyProviders and submitters can
yyProviders and submitters can successfully
submit claims with valid ICD-10
submit claims containing ICD-10 codes to
codes and ICD-10 companion
the Medicare FFS claims systems;
qualifier codes;
yySoftware changes the Centers for Medicare
yyProviders submitted claims with
& Medicaid Services (CMS) made to support
valid National Provider Identifiers
ICD-10 result in appropriately adjudicated
(NPIs)
claims; and
yyThe claims are accepted by the
yyAccurate Remittance Advices are produced.
Medicare FFS claims systems; and
yyClaims receive 277CA or 999
acknowledgement, as appropriate,
to confirm that the claim was
accepted or rejected by Medicare.
Will the testing test National No, acknowledgment testing will not
Yes, end-to-end test claims will be subject to all
Coverage Determinations
test NCDs and LCDs.
NCDs and LCDs.
(NCDs) and Local Coverage
Determinations (LCDs)?
Will the testing confirm
No, acknowledgement testing
Yes, end-to-end testing will provide an ERA
payment and return an ERA will not confirm payment. Test
based on current year pricing.
to the tester?
claims will receive 277CA or 999
acknowledgement, as appropriate, to
confirm that the claim was accepted or
rejected by Medicare.
How many claims can
There is no limit on the number of
You may submit 50 end-to-end test claims per
testers submit?
acknowledgement test claims you can test week.
submit.
How do testers submit
You submit acknowledgement
You submit end-to-end test claims directly with
claims for testing?
test claims directly or through a
test indicator “T” in the ISA15 field or through
clearinghouse or billing agency with test DDE.
indicator “T” in the Interchange Control
Structure (ISA) 15 field.
When should testers submit You may submit acknowledgement test You must submit end-to-end test claims during
test claims?
claims anytime. We encourage you
the following testing weeks:
to test during the highlighted testing
yyJanuary 26 – 30, 2015;
weeks:
yyApril 27 – May 1, 2015; and
yyMarch 2 – 6, 2015; and
yyJuly 20 – 24, 2015.
yyJune 1 – 5, 2015.
What dates of service do
You must use current dates of service
You must use the following future dates of service
testers use during testing? during acknowledgement testing.
during end-to-end testing:
HOME HEALTH & HOSPICE
Question
What will the testing show?
yyProfessional claims – Dates of service on or
after October 1, 2015;
yyInpatient claims – Discharge dates on or
after October 1, 2015;
yySupplier claims – Dates of service between
October 1, 2015, and October 15, 2015; and
yyProfessional and institutional claims – Dates
up to December 31, 2015. You cannot use
dates in 2016 or beyond.
Important Note: Remember that you must be selected by the MAC in order to participate
in end-to-end testing.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
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The chart below provides ICD-10 resource information.
For More Information About…
Resource
ICD-10
http://www.cms.gov/Medicare/Coding/ICD10/index.html on the CMS website
ICD-10 Information for Medicare
Fee-For-Service Providers
http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service-ProviderResources.html on the CMS website
ICD-10 Implementation Timelines
http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html
on the CMS website
ICD-10 Statute and Regulations
http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html on the
CMS website
All Available Medicare Learning
Network® (MLN) Products
“Medicare Learning Network® Catalog of Products” located at
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/Downloads/MLNCatalog.pdf on the
CMS website or scan the Quick Response (QR) code on the right
Provider-Specific
Medicare Information
MLN publication titled “MLN Guided Pathways: Provider Specific Medicare Resources”
located at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNEdWebGuide/Downloads/Guided_Pathways_Provider_Specific_Booklet.pdf
on the CMS website
Medicare Information for Patients
http://www.medicare.gov on the CMS website
HOME HEALTH & HOSPICE
RESOURCES
Additional Information
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
Seasonal Flu Vaccinations
Generally, Medicare Part B covers one flu vaccination and its administration per flu
season for beneficiaries without co-pay or deductible. Now is the perfect time to
vaccinate beneficiaries. Health care providers are encouraged to get a flu vaccine to help
protect themselves from the flu and to keep from spreading it to their family, co-workers,
and patients. Note: The flu vaccine is not a Part D-covered drug. For more information
on coverage and billing of the influenza vaccine and its administration, please visit MLN
Matters® Article #MM8890, “Influenza Vaccine Payment Allowances - Annual Update
for 2014-2015 Season” at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/MM8890.pdf and MLN Matters®
Article #SE1431, “2014-2015 Influenza (Flu) Resources for Health Care Professionals”
at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/SE1431.pdf.
While some providers may offer flu vaccines, those that don’t can help their
patients locate flu vaccines within their local community. The HealthMap Vaccine
Finder (http://vaccine.healthmap.org/) is a free online service where users can search
for locations offering flu and other adult vaccines. If you provide vaccination services
and would like to be included in the HealthMap Vaccine Finder database, register for
an account to submit your information in the database (http://vaccine.healthmap.org/
admin/signup/). Also, visit the CDC Influenza (Flu) Web page at http://www.cdc.gov/FLU/
for the latest information on flu including the CDC 2014-2015 recommendations for the
prevention and control of influenza.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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Stay Informed and Join the
CGS ListServ Notification Service
The CGS ListServ Notification Service is the primary means used by CGS to
communicate with home health and hospice Medicare providers. This is a free email
notification service that provides you with prompt notification of Medicare news
including policy, benefits, claims submission, claims processing and educational
events. Subscribing for this service means that you will receive information as soon as
it is available, and plays a critical role in ensuring you are up-do-date on all Medicare
information.
Consider the following benefits to joining the CGS ListServ Notification Service:
yyIt’s free! There is no cost to subscribe or to receive information.
yyYou only need a valid e-mail address to subscribe.
yyMultiple people/e-mail addresses from your facility can subscribe. We recommend
that all staff (clinical, billing, and administrative) who interact with Medicare topics
register individually. This will help to facilitate the internal distribution of critical
information and eliminates delay in getting the necessary information to the proper
staff members.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
To subscribe to the CGS ListServ Notification Service, go to http://www.cgsmedicare.
com/medicare_dynamic/ls/001.asp and complete the required information.
For Home Health and Hospice
Unsolicited/Voluntary Refunds
Providers need to be aware that the acceptance of a voluntary refund as repayment for
the claims specified in no way affects or limits the rights of the Federal Government, or
any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative
remedies arising from or relating to these or any other claims.
Medicare administrative contractors (MACs) receive unsolicited/voluntary refunds from
providers. These voluntary refunds are not related to any open accounts receivable.
Providers billing MACs typically make these refunds by submitting adjustment bills, but
they occasionally submit refunds via check. Providers billing carriers usually send these
voluntary refunds by check.
Related Change Request (CR) 3274 is intended mainly to provide a detailed set of
instructions for MACs regarding the handling and reporting of such refunds. The
implementation and effective dates of that CR apply to the carriers and intermediaries.
But, the important message for providers is that the submission of such a refund related
to Medicare claims in no way limits the rights of the Federal Government, or any of its
agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies
arising from or relating to those or any other claims.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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Upcoming Educational Events
The CGS Provider Outreach and Education department offers educational events
through webinars and teleconferences throughout the year. Registration for live events
is required. For upcoming events, please refer to the Calendar of Events Home Health
& Hospice Education Web page at http://www.cgsmedicare.com/hhh/education/
Education.html. CGS suggests that you bookmark this page and visit it often for the latest
educational opportunities.
For Home Health and Hospice Providers
Update to the Interest Paid on
Clean Non-PIP Claims Not Paid Timely
According to the Medicare Claims Processing Manual, (Pub 100-04, Ch. 1, §80.2.2),
interest is paid on clean claims, not paid under the periodic interim payment (PIP)
method, if payment is not made within 30 days after the date of receipt. The interest rate
is determined by the Treasury Department on a 6-mongh basis, effective every January
and July 1. Effective, January 1, 2015, the interest amount is 2.125%.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
Note: Interest is not paid on home health prospective payment system (HH PPS) request for anticipated
payment (RAP) billing transactions.
For additional information about when interest is paid on a claim, and how to calculate
the interest, refer to the Medicare Claims Processing Manual, (Pub 100-04, Ch.
1, §80.2.2) at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/clm104c01.pdf on the Centers for Medicare & Medicaid Services (CMS)
website. Current and past interest rate amounts can be viewed at http://fms.treas.gov/
prompt/rates.html on the Treasury Department website.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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